Is There a Post-Abortion Syndrome?

http://www.nytimes.com/2007/01/21/magazine/21abortion.t.html?ei=5088&en=5092fc3344065aec&ex=1327035600&partner=rssnyt&emc=rss&pagewanted=all


Is There a Post-Abortion Syndrome?


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By EMILY BAZELON
Published: January 21, 2007

Early on a a windy Saturday morning in November, Rhonda Arias drove her Dodge Caravan past a Wal-Mart at the end of her block and onto the Interstate. She was beginning the 50-mile drive from her house in southwest Houston to Plane State Jail, where she is, as she puts it, an “abortion-recovery counselor.” To Arias, that means helping women at the prison who have had abortions to understand how that procedure has stained them, and how it explains what has gone wrong in their lives. The prisoners’ abortions, she told me, “have a great deal to do with their pain.”
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Deborah Mesa-Pelly

In memoriam, at long last: Shrines to the aborted are a major component of "abortion-recovery counseling," allowing women an outlet to mourn.
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Times Topics: Abortion
Deborah Mesa-Pelly

Rhonda Arias As a pastor and leader of Operation Outcry, Arias ministers to women who regret their choice.
Deborah Mesa-Pelly

"Heritage Dolls" The figures used in post-abortion therapy.

Arias, who is 53, often wears silver hoop earrings and low black boots, and she has a weakness for edgy zingers. She started doing post-abortion counseling 15 years ago. After what she describes as a revelation from God, she decided that her own pain and unhappiness were rooted in the abortion she had in 1973, when she was 19. “It was the year Roe v. Wade was decided, and I remember saying, ‘No guy in Washington is going to tell me what to do with my body!’ ” Arias said with a sharp laugh as we were driving. But after the procedure, she says, strange feelings washed over her. “I remember having evil thoughts, about hurting children,” she said. “It was like I’d done the worst thing I could possibly do. A piece of evil had entered me.”

In 1983, Arias became pregnant again and planned to keep the baby. But in the fourth month, she says, she became scared about raising a child alone. She called her obstetrician. He scheduled her for a second-trimester saline abortion the following morning. Arias said she woke up from the anesthesia to the certain knowledge that she had killed her child.

Because of this knowledge, she is now equally certain, she slipped into years of depression, drinking and freebasing cocaine. One night when she was in her early 30s, she got as high as she could, lay down in the dark in a bathtub filled with water and slit her wrists. In her mind, all of her troubles — the drugs, the suicide attempt, the third and fourth abortions she went on to have, the wrestling match of a marriage she eventually entered — are the aftermath of her own original sin, the 1973 abortion. It’s a pattern she sees reflected everywhere: “In America we have a big drug problem, and we don’t realize it’s because of abortion.”

In the ’90s, Arias volunteered and then was on staff at the Women’s Pregnancy Center, a Houston group that tries to persuade women to keep their pregnancies. In 2001, after being ordained as an evangelical preacher, she founded her own abortion-recovery ministry, Oil of Joy for Mourning, named after a verse from the Book of Isaiah. She now operates 10-week counseling programs at seven penitentiaries in the state, including Plane State Jail.

When Arias talks about the effects of abortion, she’s so fervent that it’s hard to maintain her gaze. But the idea that abortion is at the root of women’s psychological ills is not supported by the bulk of the research. Instead, the scientific evidence strongly shows that abortion does not increase the risk of depression, drug abuse or any other psychological problem any more than having an unwanted pregnancy or giving birth. For Arias, however, abortion is an act she can atone for. And this makes it different from the many other sources of anguish in her past. As a child, she was sexually abused by her stepbrother, she told me. An older boy forced her to have sex when she was 14; seven months later, she says, she woke in the middle of the night to wrenching cramps and gave birth to a baby girl who was placed for adoption. A year later, Arias’s father, a bricklayer to whom she was close, plummeted from several stories of scaffolding to his death. She left home and fell out of touch with her mother and two brothers.

By concentrating on the babies she feels she has lost (she has named the first two Adam and Jason), Arias has drained other aching memories of some of their power. “I think about the baby girl I gave up for adoption, and I think I made a good parenting choice. I know she had a good life,” she said. “I think about my sons, Adam and Jason, my sons who I never held in my arms, and I know I’m forgiven. But” — her voice cracked. “I didn’t give them life. And I am so very sorry.”

Thirty-four years ago this week, the Supreme Court decided Roe v. Wade, and since then the American abortion wars have pitted the rights of “unborn babies” against those of living women. Rhonda Arias and a growing number of abortion-recovery activists want to dismantle that framework and replace it with this: Abortion doesn’t help women. It hurts them. With that conviction, these activists hope to accomplish what the anti-abortion movement has failed to do for more than three decades: persuade the “mushy middle” of the American electorate — the perhaps 40 to 50 percent who are uncomfortable with abortion but unwilling to ban it — to see that, for women’s sake, abortion should not be legal. Spread across the country are anti-abortion groups that offer post-abortion counseling. The Catholic Church runs abortion-recovery ministries in at least 165 dioceses in the United States. The federal government finances at least 50 nonsectarian “crisis pregnancy centers,” like the one where Arias worked in Houston. Many of the centers affiliate with two national groups, Heartbeat International and Care Net, which train abortion-recovery counselors. Then there are small, private counseling and Bible-study groups, both Catholic and evangelical, which raise their own money. Some abortion-recovery counselors just minister to other women. But many also feel called to join the fight to end abortion.

If the activists have a Moses, it is David Reardon, whose 1996 book, “Making Abortion Rare,” laid out the argument that abortion harms women and that this should be a weapon in the anti-abortion arsenal. “We must change the abortion debate so that we are arguing with our opponents on their own turf, on the issue of defending the interests of women,” he wrote. The anti-abortion movement will never win over a majority, he argued, by asserting the sanctity of fetal life. Those in the ambivalent middle “have hardened their hearts to the unborn ‘fetus’ ” and are “focused totally on the woman.” And so the anti-abortion movement must do the same.

For anti-abortion activists, this strategy offers distinct advantages. It challenges the connection between access to abortion and women’s rights — if women are suffering because of their abortions, then how could making the procedure readily available leave women better off? It replaces mute pictures of dead fetuses with the voices of women who narrate their stories in raw detail and who claim they can move legislators to tears. And it trades condemnation for pity and forgiveness. “Pro-lifers who say, ‘I don’t understand how anyone could have an abortion,’ are blind to how hurtful this statement can be,” Reardon writes on his Web site. “A more humble pro-life attitude would be to say, ‘Who am I to throw stones at others?’ ”

This way of thinking was first articulated in the early 1980s. Vincent Rue, a family therapist and ally of Reardon’s, testified before Congress in 1981 about a variant of post-traumatic stress disorder that he claimed was afflicting women — “post-abortion syndrome.” Six years later, Ronald Reagan asked his surgeon general, C. Everett Koop, to issue a report on the health effects of abortion. Koop was against abortion, but he refused to issue the report and called the psychological harm caused by abortion “minuscule from a public-health perspective.” Nor did Koop believe that the anti-abortion cause would be served by shifting its focus to the suffering of women. “As soon as you contaminate the morality of your stand by getting worried about the health effects of abortion on women, you have weakened the whole thing,” he said at the time in an interview with the Rutherford Institute, a conservative law center.

Mainstream anti-abortion groups didn’t shout Koop down, and the issue seemed dead. But the Catholic Church, which began financing abortion-recovery counseling in the early 1980s, continued to do so, and in 1986, Theresa Burke began developing a model of weekly support groups and later weekend retreats for women suffering from what she called post-abortion trauma. In 1993, Burke founded Rachel’s Vineyard, an independent religious group, to broaden her reach. The gatherings multiplied across the country — more than 500 retreats are planned internationally in 2007 — as well as an annual training conference. “It just grew and grew,” Burke says.

Meanwhile, the anti-abortion movement was in need of fresh ideas. Bill Clinton, in 1993, came into office as the first president to favor abortion rights in more than a decade; the Supreme Court had recently reaffirmed the right to abortion in Planned Parenthood v. Casey. Reardon’s book, published during this time of dimmed hopes for the anti-abortion movement, imagined a future in which millions of women and men with experience of abortion would express outrage, demand reform and file lawsuits that would bankrupt abortion clinics.

These millions have not materialized. The number of women who seek out groups like Rachel’s Vineyard is a small fraction of the number of American women who have abortions. Almost 3 million of the 6 million pregnancies that occur each year in the United States are unplanned; about 1.3 million end in abortion. At the current rate, about one-third of women nationally will undergo the procedure by age 45. The number of women who go to abortion-recovery counseling is probably in the tens of thousands, and the number who become dedicated activists is at most a few hundred. And yet they and their cause are emerging as a political force. “These women were minority voices for a long time, and now they are gaining traction within the anti-abortion movement,” says Reva Siegel, a Yale law professor who favors abortion rights and has been tracing this grass-roots movement from its origins.

Abortion-recovery counselors like Arias could focus on why women don’t have the material or social support they need to continue pregnancies they might not want to end. They could call for improving the circumstances of women’s lives in order to reduce the number of abortions. Instead they are working to change laws to restrict and ban abortion. In 2000, a conservative law center in Texas, the Justice Foundation, began representing Norma McCorvey — Jane Roe of Roe v. Wade. McCorvey had come to regret her role in legalizing abortion, and the Justice Foundation filed suit to reopen her case. Her lawyers argued that when the Supreme Court initially ruled in Roe, it could not have known that legalizing abortion would cause harm to women. To prove such harm exists, the Justice Foundation began collecting affidavits from women about their abortion experiences, a project it called Operation Outcry, which now has chapters in 22 states. Arias heads up Operation Outcry in Texas.

Arias raises her own money for the prison counseling and to speak at rallies and to legislatures in her state and around the country, telling her story and urging women to send in affidavits. The Justice Foundation has also collected affidavits through counseling programs like Rachel’s Vineyard, along with a hot line for post-abortive women and a television program, “Faces of Abortion,” which features interviews with women who regret their abortions and which appears on satellite networks that reach 10 million homes. To date, 1,940 women have submitted Operation Outcry affidavits.

Last year, the Supreme Court refused to hear McCorvey’s case. But the affidavits continue to be used as evidence in other litigation, including the so-called partial-birth-abortion case that is currently before the Supreme Court. Similar testimony has also been submitted in two cases that involve efforts to raise the standard for informed consent, which abortion providers must obtain from their patients. “There will be a great deal of litigation in this area,” says Roger Evans, Planned Parenthood’s senior director for public policy, law and litigation. “This is where they are headed.”

Abortion-recovery activists may well have the greatest impact in statehouses. When the South Dakota Legislature banned abortion in 2005, it relied on a state task-force report, which said that women cannot end their pregnancies without “suffering significant psychological trauma and distress,” because “to do so is beyond the normal, natural and healthy capability of a woman whose natural instincts are to protect and nurture her child.” This “woman-protective anti-abortion argument,” Siegel points out in a coming article in The University of Illinois Law Review, “mixes new ideas about women’s rights with some very old ideas about women’s roles.”

In 1985, Reardon started a social-science fight over the effects of abortion. He surveyed members of a group called Women Exploited by Abortion (since disbanded), which defined itself as a “refuge” for “post-abortive women.” Reardon distributed a survey to about 250 WEBA members and found high rates of nervous breakdowns, substance abuse and suicide attempts. He presented this as proof of a national link between abortion and these conditions.

Soon after Koop’s refusal in 1987 to report on the health effects of abortion, the American Psychological Association appointed a panel to review the relevant medical literature. It dismissed research like Reardon’s, instead concluding that “well-designed studies” showed 76 percent of women reporting feelings of relief after abortion and 17 percent reporting guilt. “The weight of the evidence,” the panel wrote in a 1990 article in Science, indicates that a first-trimester abortion of an unwanted pregnancy “does not pose a psychological hazard for most women.” Two years later, Nada Stotland, a psychiatry professor at Rush Medical College in Chicago and now vice-president of the American Psychiatric Association, was even more emphatic. “There is no evidence of an abortion-trauma syndrome,” she concluded in an article for The Journal of the American Medical Association.

Academic experts continue to stress that the psychological risks posed by abortion are no greater than the risks of carrying an unwanted pregnancy to term. A study of 13,000 women, conducted in Britain over 11 years, compared those who chose to end an unwanted pregnancy with those who chose to give birth, controlling for psychological history, age, marital status and education level. In 1995, the researchers reported their results: equivalent rates of psychological disorders among the two groups.

Brenda Major, a psychology professor at the University of California, Santa Barbara, followed 440 women for two years in the 1990s from the day each had her abortion. One percent of them met the criteria for post-traumatic stress and attributed that stress to their abortions. The rate of clinical depression among post-abortive women was 20 percent, the same as the national rate for all women ages 15 to 35, Major says. Another researcher, Nancy Adler, found that up to 10 percent of women have symptoms of depression or other psychological distress after an abortion — the same rates experienced by women after childbirth.

Researchers say that when women who have abortions experience lasting grief, or more rarely, depression, it is often because they were emotionally fragile beforehand, or were responding to the circumstances surrounding the abortion — a disappointing relationship, precarious finances, the stress of an unwanted pregnancy.

But David Reardon continues to research the psychological effects of abortion, and he no longer makes beginner’s mistakes. He is said to have a doctorate in biomedical ethics from Pacific Western University, an unaccredited correspondence school, according to Chris Mooney, the author of “The Republican War on Science.” (Reardon did not respond to several requests to be interviewed.) According to his Web site, in 1988, Reardon founded the Elliot Institute, a research center in Springfield, Ill., which in 2005 had a $120,000 budget. He has recently teamed up with Priscilla Coleman, a professor of family and consumer studies at Bowling Green State University in Ohio, and published more than a dozen papers in peer-reviewed journals. Reardon and Coleman cull data from national surveys and state records in which unplanned pregnancy is not the focus of the data collection. Using the National Longitudinal Survey of Youth, Reardon found a higher risk of clinical depression in a group of married women who had abortions, and published the results in a 2002 article in The British Medical Journal; using California Medicaid records, he and Coleman found a higher risk of psychiatric hospital and clinic admissions among poor post-abortive women, which they reported in 2003 in The Canadian Medical Association Journal; two years later, using the National Survey of Family Growth, they found a higher risk of generalized anxiety disorder post-abortion and published their results in The Journal of Anxiety Disorders.

Nancy Russo, a psychology professor at Arizona State University and a veteran abortion researcher, spends much of her professional time refuting Reardon and Coleman’s results by retracing their steps through the vast data sets. Russo examined the analysis in the 2002 and 2005 articles and turned up methodological flaws in both. When she corrected for the errors, the higher rates of mental illness among women who had abortions disappeared. Russo published her findings on depression in The British Medical Journal last year; her article on anxiety disorders is under review. “Science eventually corrects itself, but it takes a while,” she says. “And you can feel people’s eyes glaze over when you talk about coding errors and omitted data sets.” Priscilla Coleman, for her part, says that research that concludes that abortion has negative effects is more scrutinized because it’s “so politically incorrect.” When researchers attack his findings, Reardon writes to the journals’ letters pages. “Even if pro-abortionists got five paragraphs explaining that abortion is safe and we got only one line saying it’s dangerous, the seed of doubt is planted,” he wrote in his book.

The A.P.A. has convened a new task force to review the more recent scientific literature about the effects of abortion; the panel will issue findings in 2008. Assuming the A.P.A. affirms the prevailing social-science research, the belief that abortion harms women may be hard to dislodge. Even if no solid evidence provides a causal link to increased rates of depression or other emotional problems, abortion is often a grim event. And for a minority of women, it is linked to lasting pain. You don’t have to be an anti-abortion advocate to feel sorrow over an abortion, or to be haunted about whether you did the right thing.

Rhonda Arias, however, heeds a simpler call: repent, and save other women from doing what you did. That is the gospel she preaches in the Texas prisons. On the drive to Plane State Jail, Arias talked about her daughters. Jessica, 20, is an art student in Florida. Jacqui, 17, and Joanna, 13, live at home. Arias was married to the girls’ father for 18 years before the two divorced last year.

Arias told Jessica and Jacqui about her abortions when they were 9 and 6. She wanted to ask for their forgiveness. A few years ago, Jacqui taped a segment of the TV program “Faces of Abortion,” in which she said that as a child, she tried to behave so her mother wouldn’t wish she’d aborted her, too. That made Arias wonder whether she’d been unwise to talk to the girls when they were so young. “I wished I’d asked myself if they were developmentally ready,” she told me.

Last March, Arias took Jessica on a monthlong ministry to Israel. They are both interested in Messianic Judaism — a mezuza is nailed to the doorpost of the family’s home. For Arias, the trip was glorious. She ministered on Ben Yehuda Street in Jerusalem. (On a previous trip she threw her wedding ring into a valley, pledging to live as a new virgin.) She returned home to the news that Jacqui was pregnant. “I was the last person they told,” she said of Jacqui and her boyfriend, whom Jacqui met in church. Arias taught her daughters about saving themselves for marriage but not about contraception. “Abstinence works better than birth control, really,” she said. “It’s just that people don’t do it.” Jacqui’s father pressured her to have an abortion; Jacqui warded him off. And then she and Arias started planning for the baby, who was born in December.

In the parking lot of Plane State, Arias paused to finish a cup of coffee and to pray. “Oh, Lord, I go from prison to prison, hundreds of women and thousands of babies, and sometimes I feel like I’m carrying a lot of grief,” she said in a whisper. Outside, the wind blew through a row of spindly trees. Arias closed her eyes and gripped the steering wheel. “Lord Jesus, carry this grief. It’s too heavy for me. I ask you to take it from me and from these women. I implore you. Lift it from their shoulders. Deliver us, Lord.”

At the entrance to the jail, Arias met three Oil of Joy volunteers: Nikki Heitzeberg and Debbie Harper, whom she knows through abortion-recovery counseling, and Shawna Kimbrough, who joined the group after fleeing New Orleans for Houston during Hurricane Katrina. Unlike the other volunteers, Kimbrough is black, and Arias says she values the connection Kimbrough makes to African-American prisoners.

Over 10 weeks in Oil of Joy, participants talk about their views of God and of the men in their lives. They fill out an “emotion time line” to chart their lives. They explore the circumstances of their abortions. They’re encouraged to think about whether they were pressured into ending their pregnancies and to connect this with other experiences of feeling powerless. Often, Arias says, they are victims of physical or sexual abuse. They fill “bitterness bags” with rocks, one for each offense they want to forgive, often including those they committed themselves. They pick out a pair of baby shoes — choices include satin christening slippers, work boots, sneakers and Dora the Explorer flip-flops — attach a card with the name they have chosen for the baby they didn’t have and give them to Arias for a traveling memorial that she has taken to Washington, D.C. During the ninth session, which was taking place the day I was there, Arias held a memorial service for the prisoners’ aborted and miscarried babies.

Inside the Tom Baker Chapel of Hope at the jail, Harper and Kimbrough arranged long pieces of gauzy white cloth over the altar and onto the floor, so that the material lined a short aisle. Into the cloth they tucked white teddy bears with red hearts around their necks that read “Happy Mother’s Day” and “No. 1 Mommy.” Kimbrough sprinkled silk rose petals over the altar and floor. On a side table, Arias placed baskets of cloth “heritage dolls.” Their heads and hands were tied with thin ribbons. Their faces were blank. Heitzeberg erected a curved metal frame over the altar and draped it with more white cloth. Kimbrough climbed on a chair to hang a string of Christmas lights over the top. Arias surveyed the altar. “It looks like a bassinet,” she said approvingly. The volunteers arranged a semicircle of 25 chairs up front, with sheets of pink Kleenex on each seat.

A guard came in. “Last time, I was in here crying myself,” the guard said, and then dimmed the lights and cued soft gospel music over a sound system. About two dozen inmates filed into the chapel, wearing white V-neck prison uniforms, canvas sneakers and orange plastic wrist bands. They’d been instructed to enter quietly. Some oohed at the lights over the altar. Others walked in sniffling. The volunteers greeted them with hugs.

The group sat, and Arias took the microphone. “Today we mourn for your children,” she said. The sniffling grew louder. “Many of you never got a chance to mourn the loss of your sons and daughters. Today you have permission to cry, to feel the feelings you’ve pressed down for so long.” Kimbrough passed out more Kleenex.

Arias wove a sermon from Biblical stories: Jesus meeting the woman at the well in Samaria, Hannah praying to God to give her a child, Eve celebrating the birth of her sons. It was time, Arias told the inmates, to release their babies to the Lord. Kimbrough and Harper passed around the baskets of heritage dolls, telling the women to take one for each baby they’d aborted or miscarried. The women rocked the blank-faced dolls, many holding three or four. Their faces dampened with tears. The music reached a crescendo as a singer crooned: “Holy child from God’s great hands/is a holy word from God to man/How long will we push our children away?/Is there room in our world for a new word today?” One prisoner took her Bible from under her chair. Inside was a photograph of two elementary-school-age girls with ponytails — her daughters. She kissed their images.

For a few minutes, Arias let the women cry. Then she put out a hand to quiet the sobbing around her. “Is my Jason a 25-year-old-man now, or is he still a little baby?” she asked, her voice high and trembling. “We are very limited in our understanding. But Corinthians tells us that what has died will be resurrected. You might think about your D and C”— the abortion method dilation and curettage — “and wonder how does your baby’s body look, since it went through that little tube. The Bible tells us, ‘The body is sown into corruption.’ I can’t think of anything more corrupt than going through a tube or being ripped apart by an abortionist. But surely in heaven the body is made whole.”

Arias moved forward, closer to the women. “And in heaven, our children will know us when they see us. They will call, ‘Mommy!’ and they will reach out their arms” — she extended hers — “and they will embrace us! They’re not going to ask, ‘What did you do that for?’ They already know. They know more than you do. I have a 17-year-old who thinks she knows more than me. She is wrong.” A few wry laughs broke through the crying. “But I have four children in heaven who really do know more than I do. To get to heaven, you have to be forgiven, and you must forgive others.”

She instructed the women to stand up, speak in memory of their lost babies and take their heritage dolls to the altar. The women stood one by one. They clutched their dolls and said they were sorry. They imagined a baby with his father’s dimple or curly hair or green eyes. One woman mentioned a child who had been born and taken into state custody, and the woman who kissed the pictures of her daughters sent them her love. For the most part, though, the messy mothering of living children — and the reality of their lives outside the prison — did not intrude on the ceremony. The women focused on mourning the elusive, innocent loss represented by the dolls. They gave them fairy-tale names: Sarah Jewell, Angel Pillow, Xavier Dante. At a side table, Kimbrough and Harper wrote the names on certificates for children “expected to be born.” The documents promised, “By virtue of being conceived, the spirit of this child lives eternally with Jesus and in the heart and the mind of the mother, now and forevermore.”

After the certificates were filled out and the women returned to their seats, Kimbrough gave a closing prayer. “I thank you for Sister Rhonda, who has laid down years of her life that we may have healing and closure,” she said. Women shouted, “Yes, Lord!” and beamed at Arias. She smiled back, and then her face got stern. “I want to ask you a question,” she said. “If you found yourself in the situation of another crisis pregnancy, would you consider abortion?”

“No!” a chorus shouted.

“Can you see yourself living a life of chastity when you leave this place?”

This time, the response was muted. Arias talked about her vow of chastity and then nodded to the guard working the sound system. The music changed to an upbeat song. The women danced, crying and hugging. An older inmate with long hair began calling to Jesus, her screams shrill and shaky. She lapsed into loud sobbing. Heitzeberg patted her on the back. “Hallelujah!” Arias cried. “I don’t know what God did here, but I know it’s good.”

It was nearly 2:30 p.m. The women had been in the chapel for three hours. Arias called them back to their seats. One prisoner raised her hand to ask how she could help in the fight against abortion. “I’m so glad you brought that up,” Arias said, and described Operation Outcry. She asked the women their release dates and told them how to send in an affidavit and sign up on her Web site once they’d left the jail. “Ladies, thank you for your courage,” Arias concluded. The women went up shyly to say goodbye. Then they shuffled out of the chapel.

While it seems that some anti-abortion advocates exaggerate the mental-health risks of abortion, some abortion advocates play down the emotional aftereffects. Materials distributed at abortion clinics and on abortion-rights Web sites stress that most women feel relief after an abortion, and that the minority who don’t tend to have pre-existing problems. Both claims are supported by research. But the idea that “abortion is a distraction from underlying dynamics,” as Nancy Russo put it to me, can discourage the airing of sadness and grief. “The last thing pro-choice people, myself included, want to do is to give people who want to make abortions harder to get or illegal one iota of help,” says Ava Torre-Bueno, a social worker who was the head of counseling for 10 years at Planned Parenthood in San Diego. “But then what you hear in the movement is ‘Let’s not make noise about this’ and ‘Most women are fine, I’m sure you will be too.’ And that is unfair.”

Initially, Torre-Bueno’s encounters with grieving patients surprised her, because sadness wasn’t an issue in the first years after Roe. “In 1975, I’d say, ‘I wonder how you’re feeling,’ and women would answer, ‘Thank God it’s legal!’ ” she says. But by the early 1980s, Torre-Bueno and a handful of other counselors who favor abortion rights say, the emotional tide began to turn along with the political one. Congress cut off Medicaid money for abortion. The Supreme Court retrenched. Protesters picketed clinics and made bomb threats. Some clinic directors decided it was not enough to treat abortion as a straightforward medical procedure. Charlotte Taft, who founded an abortion clinic in Dallas in 1978, later began practicing what she calls “emotional triage” to identify women at risk of adverse reactions. She would ask prospective patients: Are you against abortion but feel you have no choice? Do you believe that abortion is murder? Do you think God will never forgive you? Is someone pressuring you? Do you have a history of depression? “Some women are clearly fine,” Taft told me. “Others are torn apart, and they need more process.” When women answered Taft’s questions by saying things like “I’m going to hell, but I have to do this,” Taft sent them home with exercises to help them work through their emotions.

In 1989, two dozen like-minded abortion providers started a group they called the November Gang. In hopes of improving pre-abortion counseling, Peg Johnston, founder of Southern Tier Women’s Services in Binghamton, N.Y., wrote a 90-page pregnancy-options workbook, which she says she gives to women who are ambivalent and to those who are grieving after their abortions, about 10 percent of her clients; it asks them if they feel fear and shame and tries to help them with these feelings. While abortion-rights advocates frame abortion as a woman’s legal right, the November Gang providers tend to think in terms of a woman’s responsibility to decide when and whether to bring life into the world. And instead of telling women who grieve over their abortions to look elsewhere for the source of their distress, they try to use the moment as a catalyst. Sometimes an abortion “pops open the box where old anxieties have been kept,” Torre-Bueno says. “It’s an opportunity to revisit past traumas like child abuse, or to face them for the first time.” This doesn’t mean that the abortion was a mistake, or that other circumstances — the unresolved past, a loutish boyfriend, money problems — aren’t the real trouble, Torre-Bueno reasons. But women sometimes need help sorting this out.

In her 1994 book, “Peace After Abortion,” Torre-Bueno talks about the pain some women feel on the anniversary dates of their abortions, the spiritual conflict to which abortion can give rise and the hurt caused by keeping it secret — all topics in abortion-recovery counseling. She describes grieving rituals: writing a letter to whomever the woman feels she has harmed (the baby, herself, God, her partner), lighting a candle, filling and then burning a “letting go” box. Adapting the Jewish ritual of placing stones on the tombstones of departed loved ones, Peg Johnston offers a “worry stone” to patients at her clinic, to “give them strength through the procedure.”

These counselors don’t suggest that women should need to heal from an abortion, or that most women do need to. And they are avowedly in favor of abortion rights. Still, the position of these providers within their own movement is tenuous. Torre-Bueno says that when she self-published her book and asked if she could hold a book party at Planned Parenthood in San Diego, the director said no. “He called me a ‘dupe of the antis,’ ” she remembers. (The director, who has since retired, says he doesn’t remember the conversation.) In 1995, after 17 years directing the Dallas clinic, Charlotte Taft says she resigned because the owner wanted to run a more traditional practice. By then, she says, Planned Parenthood had stopped sending her referrals.

The country’s largest abortion provider, with more than 77 clinics around the country, Planned Parenthood has standards for informed consent, and these acknowledge that some women experience sadness or guilt, adding that “these feelings usually go away quickly” and that “serious psychiatric disturbances” occur rarely. The National Abortion Federation, an umbrella group for abortion clinics, has similar guidelines. In practice, pre-abortion counseling varies. Many clinics say that women are encouraged to talk about their feelings but aren’t asked the pointed questions that Taft posed. “That sets people up as having to defend themselves and tell us personal things,” says Leslie Rottenberg, director of Planned Parenthood’s Manhattan center. “You should be able to make an appointment regardless of your beliefs or feelings. It’s a question of access.”

Rottenberg’s clinic provides post-abortion counseling — one or two sessions with a social worker — to any patient who asks for it. Other clinics can’t afford to offer that service and refer women who need help to local clergy members or therapists. Few clinics run support groups. Those who do say they’re often undersubscribed. It may be that women who experience grief after an abortion are more comfortable receiving counseling outside a clinic. Many providers have lately referred patients to a hot line called Exhale, founded seven years ago by Aspen Baker, shortly after she had an abortion when she was 23 and a recent graduate of U.C. Berkeley. Baker assumed counseling would be offered after the procedure. It wasn’t. She volunteered at California Naral and tried to talk about the sadness she was feeling. No one seemed receptive. So Baker raised $1,000 from friends and in 2002 set up Exhale as a volunteer-staffed hot line based in Oakland, Calif. She favors abortion rights, but her aim is to counsel women without taking sides in the debate. Since Exhale’s services became nationally available in June 2005, the hot line has received an average of 300 calls a month. A similar service, Backline, started in Portland, Ore., two years ago.

The abortion providers I talked to were unanimous in their praise for Exhale. Yet so far, this hasn’t translated into much financial support. Exhale has an annual budget of $315,000, most of which comes from foundations that don’t advocate for or against abortion. Backline’s budget is a tiny $36,000. Its founder, Grayson Dempsey, maintains that there is a demand for pro-choice post-abortion support groups and retreats. But she can’t afford to fill it.

There is considerably more money for post-abortion counseling on the anti-abortion side. In addition to the diocese-based services paid for by the Catholic Church, the Bush administration, in its first four years, spent more than $30 million on the 50-some crisis pregnancy centers, according to a report by Representative Henry A. Waxman, a Democrat from California.

Last summer, Waxman’s office investigated some of the crisis pregnancy centers and found that when women there asked about abortion’s health effects, 20 of 23 centers gave out false information. At 13 centers, this included characterizing the psychological effects of abortion as “severe, long-lasting and common.” “One center said that the suicide rate in the year after an abortion ‘goes up by seven times,’ ” Waxman’s report states.

Religious abortion-recovery programs don’t qualify for government money. Rachel’s Vineyard relies on financing from Priests for Life, a $7 million anti-abortion group that is independent of the Catholic Church. Oil of Joy’s finances are tighter. Last year, Arias raised $34,000. She is straining to pay her mortgage; meanwhile, as the Texas leader of Operation Outcry, she is expected to make donations to the Justice Foundation, which has a $1 million annual budget and paid its lead lawyer, Allan Parker, $123,000 in 2005.

While national groups like Focus on the Family, the National Right to Life Committee and Concerned Women for America warn about the dire effects of abortion on their Web sites and link to counseling ministries like Rachel’s Vineyard, they don’t finance abortion-recovery counseling. In part, that may be because the government and the Catholic Church do. But the lack of money may also reflect the strain of skepticism that Koop voiced. Francis Beckwith, a professor of church-state studies at Baylor University who is anti-abortion, has criticized abortion-recovery activists for their “questionable interpretation of social-science data” and for potentially undermining the absolutist moral argument against abortion. “For every woman who has suffered trauma as a result of an abortion, I bet you could find half a dozen who would say it was the best decision they ever made,” he told me. “And in any case, suffering isn’t the same as immorality.” Beckwith speaks at churches and colleges, and he says that most anti-abortion leaders don’t want the woman-protective argument to supersede the traditional fetus-centered focus, “because that’s where the real moral force is.”

These tensions surfaced in the campaign to retain South Dakota’s abortion ban. The state leader for the anti-abortion side, Leslee Unruh, who had an abortion in her 20s, called on post-abortive women to campaign and started a state tour for them called Fleet for Little Feet. Unruh says, “My strategy was to put the women on TV and have them tell their stories.” But the national pro-life groups refused to send her money to run those TV ads early in the election cycle, she says. “They won’t acknowledge women as the first victim. We’re always second to the baby.” Polls show that voters rejected the ban (by a 55 percent to 45 percent margin) because it did not include an exception for rape and incest survivors. But Unruh blames internal division. “I can tell you that the support I needed from the national groups I did not get,” she says. “I just got talk.”

One theme in the Justice Foundation’s 1,940 affidavits is the story of the woman who says that she was told at an abortion clinic she was carrying “a blob of tissue” and that she went through with the procedure only because of this lie. This narrative is being used in two pending lawsuits over what constitutes informed consent. In one suit in Middlesex County, N.J., Rosa Acuna claims that in April 1996, when she asked her doctor in the sixth or seventh week of her pregnancy whether “the baby was already there,” he answered, “Don’t be stupid, it’s only blood.” She is suing for emotional distress. The doctor denies the allegation. But the case is at a preliminary stage in which the question is whether Acuna can try to prove her allegations at a trial. Last April, the appellate division of the New Jersey courts said she could. The question at trial, the court said, would be what medical information a doctor must disclose “when the patient asks if the ‘baby’ is already ‘there.’ ”

If what Acuna says is true, then her doctor may have breached his duty by lying to her about the basic facts of pregnancy. But Acuna’s lawyer, Harold Cassidy, argues in court documents not that her doctor should have told her she was carrying an embryo but that he had a duty to tell her that the embryo “was a complete, separate, unique and irreplaceable human being.” Later this year, the Supreme Court of New Jersey will review Acuna’s case. A key issue is whether her trial will include evidence about the human status of the fetus. Cassidy argues that this is a medical fact. The doctor’s lawyers say it is a religious and philosophical question.

Cassidy is also involved in defending a 2005 South Dakota informed-consent law, which Planned Parenthood has challenged. In its 1992 ruling in Casey, which affirmed (with some caveats) the right to legal abortion enshrined in Roe, the Supreme Court said that states can require doctors to give patients “truthful and not misleading” information about abortion. Eighteen states include in their materials a description of abortion’s psychological effects. According to a 2006 analysis by the Guttmacher Institute, seven of these states describe only harmful effects. South Dakota’s informed-consent law requires physicians to give patients written state-approved information that supplies a link between abortion and an increased risk of suicide, though no causal connection has been found. Both the patient and the doctor must certify that the patient has read and understood the materials; failure to do so is a misdemeanor offense.

Does such a law violate a doctor’s constitutional right to free speech? Robert Post, a Yale law professor, argues that the state should not be able to force doctors to convey inaccurate or misleading information. South Dakota’s law “endangers the integrity of physician-patient communications, because it threatens to transform physicians into mouthpieces for political majorities,” he writes in a coming law-review article.

South Dakota’s law also requires abortion providers to tell their patients what Cassidy argues Acuna’s doctor should have told her in the New Jersey case — “that the abortion will terminate the life of a whole, separate, unique, living human being.” A federal district judge agreed with Planned Parenthood that the law would force doctors to articulate the state’s viewpoint on “an unsettled medical, philosophical, theological and scientific issue, that is, whether a fetus is a human being.” The judge granted a preliminary injunction that prevented the informed-consent provisions from taking effect. In October, a three-judge panel of the United States Court of Appeals for the Eighth Circuit affirmed that ruling. But the panel’s decision was vacated this month when the Eighth Circuit as a whole voted to rehear the case in April. The question of whether the state can require doctors to say that a fetus is a full human being and that abortion increases the risk of suicide is in legal limbo.

On a rainy morning in November, a dozen women gathered a block from the Supreme Court, at a row house owned by the Gospel of Life Ministries, an anti-abortion group. The women planned to spend the day rallying on the steps of the court while the justices heard a challenge to the federal partial-birth-abortion ban. They came from a constellation of groups: Operation Outcry; Rachel’s Vineyard; Project Rachel, the abortion-recovery ministry of the Catholic Church; and the Silent No More awareness campaign. Like Rachel’s Vineyard, Silent No More gets money from Priests for Life; it also has the backing of Anglicans for Life, another independent group. Once inside, the women closed their umbrellas and handed out mugs of coffee. Georgette Forney and Janet Morana, co-founders of Silent No More, checked on late arrivals from their cellphones. Theresa Burke was on her way from Pennsylvania. Alveda King, the niece of Martin Luther King Jr., would arrive later from Atlanta.

At the courthouse, the women unfurled banners and signs that read, “I Regret My Abortion” and lined up to hold them. A giant picture of a bloody fetus floated above the crowd. Behind Forney’s group, two dozen people in NOW and Naral T-shirts chanted: “Right to life, that’s a lie. You don’t care if women die,” and “You get pregnant, let me know. Anti-choicers got to go.” Forney eyed them. “All these years and they still haven’t figured out it would be wise to find common ground with women like us,” she said.

I asked her what she had in mind. She talked about making abortion “unthinkable” by making sure that women have better choices. At first this sounded like Bill Clinton’s “safe, legal and rare” formulation, or Hillary Clinton’s characterization of abortion as a “tragedy.” But along with promoting adoption, the reforms Forney and Morana described were Baby Moses laws, which make it easier not for women to avoid pregnancy in the first place or to take care of children to whom they give birth but to abandon newborns at places like fire stations and hospitals.

Forney and Morana compare abortion to smoking. “The suppression of truth about the harms of abortion is the same as the suppression of truth about the harms of cigarettes,” Morana said. Once the public understands the trauma of abortion, as they now do the health problems associated with cigarettes, then “changing the law will be an afterthought,” Forney predicted.

Rhonda Arias says she does not think that abortion will quietly disappear. She wants states to ban abortion outright, Roe or no Roe, “to end this covenant of death.” We were talking on the Sunday morning after the visit to Plane State Jail. Arias was stretched out on the couch in her living room; without makeup, her face looked lived-in and also alight. She opened her Bible to the first Book of Kings, Chapter 11. “Solomon builds a temple for Moab and Moloch — the false god who demanded child sacrifice,” she recounted. “And then ‘the Lord therefore said to Solomon: Because you have done this, and have not kept my covenant, and my statutes, which I have commanded you, I will surely tear the kingdom, and give it to your servant.’ So you see, when we allow the killing of children, we defy the will of God. There is so much blood defiling the land.”

Arias hugged a pillow to her and unwrapped a favorite memory. A few years ago, after she preached at a pro-life rally on the steps of the state capitol in Austin, a man jumped out of his pickup truck and grabbed her. “He said, ‘You made me want to worship God!’ That is the highest compliment anyone ever paid me.”

At the prison the day before, I watched the inmates drink in Arias’s preaching, too. Abortion-rights leaders would accuse her of manipulation, of instilling guilt in women to serve the anti-abortion movement’s political ends. But Rhonda Arias ministers from the heart; the lack of scientific support for her ideas merely underscores that she is a true believer.

Her ardor and influence is better explained, perhaps, by the theory of social contagion, which psychologists use to explain phenomena like the Salem witch trials or the wave of unfounded reports of repressed memories of sexual abuse. Reva Siegel of Yale compares South Dakota’s use of criminal law to enforce a vision of pregnant women as weak and confused to the 19th-century diagnosis of female hysteria. These ideas can make and change laws. The claim that women lacked reliable judgment was used to deny women the vote and the right to own property. Repressed-memory stories led states to extend their statutes of limitations. Women who devote themselves to abortion recovery make up for the wrong they feel they’ve done by trying to stop other women from doing it too — by preventing them from having the same choices.

And then there is the relief in seizing on a single clear explanation for a host of unwanted and overwhelming feelings, a cause for everything gone wrong. When Arias surveyed 104 of the prisoners she had counseled in 2004, two-thirds reported depression related to abortion, 32 percent reported suicide attempts related to abortion and 84 percent linked substance abuse to their abortions. They had a new key for unlocking themselves. And a way to make things right. “You have well-meaning therapists or political crusaders, paired with women who are troubled and experiencing a variety of vague symptoms,” Brenda Major, the U.C. Santa Barbara psychology professor, explained to me. “The therapists and crusaders offer a diagnosis that gives meaning to the symptoms, and that gives the women a way to repent. You can’t repent depressive symptoms. But you can repent an action.” You can repent an abortion. You can reach for a narrative of sin and atonement, of perfect imagined babies waiting in heaven.

Emily Bazelon is a senior editor at Slate and frequently writes about the law and science. Her last feature article for the magazine was about Wendy Mogel, a psychologist who uses Jewish teachings in her practice.
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