Abortion as stigma: cognitive and emotional implications of concealment

Stigma and abortion complications: stories from three continents

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively “marked” by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma – particularly its impact on abortion complications – have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Secretive and close? How sharing secrets may impact perceptions of distance

Having secrets is incredibly common. However, secrecy has only recently started to receive more attention in research. What has largely been neglected so far are the consequences of secret-sharing for the relationship between sharer and receiver. In this project, we aim to fill this gap. Previous research has shown that closeness can make secret-sharing more likely. Building on research from the self-disclosure and relationship literature, we experimentally investigate whether secret-sharing might in turn increase perceptions of closeness. In addition, we test the valence of the secrets shared as potential driver of the hypothesized effect, as negative secrets might signal a high level of trust, but might also present a burden to the receiver. To provide a holistic picture, we build on a variety of methods to investigate three perspectives: Study 1 focuses on the receiver and tests whether another person sharing secrets (vs. nonconfidential information) decreases distance in the eyes of the receiver. Study 2 investigates lay theories and tests how an observer perceives the relationship between two people who share secrets (vs. nonconfidential information). Study 3 tests whether these lay theories about sharing secrets are predictive of behavior, and how a sharer might choose secrets of negative or positive valence to decrease perceived distance on the receiver’s side. Our results will contribute to the understanding of how sharing secrets affects the way individuals think about each other, how close they feel to each other, and how they interact with each other.

Experiences of harassment and empowerment after sharing personal abortion stories publicly

Objective

In recent years, in an attempt to counter stigma and increase empathy, public education campaigns have encouraged people to share their personal abortion stories. This exploratory study sought to document negative and positive experiences of those who have shared their abortion stories publicly.

Study design

We conducted an anonymous online survey of people who have shared their abortion story publicly (N = 88), recruited via partners affiliated with two abortion story-sharing campaigns. The survey asked about the context in which respondents shared their abortion story, any negative and positive experiences online and in “real life” as a result of story sharing, and any problems or benefits resulting from these experiences. We analyzed survey data using descriptive statistics, bivariate analyses and categorizing responses to open-ended questions.

Results

Sixty percent of respondents reported experiencing harassment and other negative incidents after sharing their story publicly. These experiences contributed to emotional stress, problems with loved ones and difficulties at work and/or school. These harms were reported even by many respondents who used only a first name or alias when sharing their story. Despite this, positive experiences as a result of story sharing were reported by four out of five respondents and motivated many to continue sharing their story.

Conclusions

This exploratory study indicates that many people who share their abortion story publicly find it to be an empowering, rewarding experience. Yet they also experience harassment and threats at high rates. Future research should explore both positive and negative experiences in more depth.

Implications

Sharing one's personal abortion story as part of a public education campaign can be a positive, empowering experience. Nevertheless, policymakers, journalists and reproductive health advocates should recognize the potential harms experienced by people who share their abortion story publicly and consider measures to support these individuals.

Atheism as a Concealable Stigmatized Identity: Outness, Anticipated Stigma, and Well-Being

In a preliminary exploration of atheists using a concealable stigmatized identity framework, we investigated outness, identity magnitude, anticipated stigma, and psychological and physical well-being. Atheists ( N = 1,024) in the United States, completed measures of outness, atheist identity magnitude, anticipated stigma, and psychological and physical well-being online. Consistent with predictions, we found small but significant associations between (a) anticipated stigma and well-being, (b) social components of atheist identity magnitude and outness as well as well-being, and (c) outness and well-being. A significant and moderate association was found between anticipated stigma and outness. There were significant, small indirect effects of ingroup ties, a social component of atheist identity magnitude, on psychological and physical well-being via outness; and of ingroup affect, another social component of magnitude, on psychological well-being via disclosure of atheist identity. Implications for research, practice, and training are offered.

Do perceived contraception attitudes influence abortion stigma? Evidence from Luanda, Angola

Abortion stigma is influenced by a variety of factors. Previous research has documented a range of contributors to stigma, but the influence of perceived social norms about contraception has not been significantly investigated. This study assesses the influence of perceived social norms about contraception on abortion stigma among women in Luanda, Angola. This analysis uses data from the 2012 Angolan Community Family Planning Survey. Researchers employed multi-stage random sampling to collect demographic, social, and reproductive information from a representative sample of Luandan women aged 15-49. Researchers analyzed data from 1469 respondents using chi-square and multiple logistic regression. Researchers analyzed women's perceptions of how their partners, friends, communities, and the media perceived contraception, and examined associations between those perceptions and respondents' abortion stigma. Stigma was approximated by likelihood to help someone get an abortion, likelihood to help someone who needed medical attention after an abortion, and likelihood to avoid disclosing abortion experience. Higher levels of partner engagement in family planning discussion were associated with increased stigma on two of the three outcome measures, while higher levels of partner support of contraception were associated with decreased stigma. Perceived community acceptance of family planning and media discussion of family planning were associated with a decrease in likelihood to help someone receive an abortion. These results suggest that increasing partner support of family planning may be one strategy to help reduce abortion stigma. Results also suggest that some abortion stigma in Angola stems not from abortion itself, but rather from judgment about socially unacceptable pregnancies.

Ethics challenges and guidance related to research involving adolescent post-abortion care: a scoping review

Introduction

An increase in post abortion care (PAC) research with adolescents, particularly in low- and middle-income countries, has brought to attention several associated research ethics challenges. In order to better understand the ethics context of PAC research with adolescents, we conducted a scoping review of published literature.

Methods

Following a systematic search of PubMed, HINARI, and Google Scholar, we analysed articles meeting inclusion criteria to determine common themes across both the ethical challenges related to PAC research with adolescents and any available guidance on the identified challenges.

Results

The literature search identified an initial 3321 records of which 14 were included in analysis following screening. Several ethical challenges stem from abortion being a controversial, sensitive, and stigmatized topic in many settings. Ethical dilemmas experienced by researchers conducting adolescent PAC research included: difficulties in convincing local health providers to permit PAC research; challenges in recruiting and seeking consent due to sensitivity of the subject; effectively protecting confidentiality; managing negative effects of interventions; creating a non-prejudicial atmosphere for research; managing emotional issues among adolescents; and dealing with uncertainty regarding the role of researchers when observing unethical health care practices. Suggested strategies for addressing some of these challenges include: using several sources to recruit study participants, using research to facilitate dialogue on abortion, briefing health workers on any observed unethical practices after data collection, fostering a comprehensive understanding of contextual norms and values, selecting staff with experience working with study populations, and avoiding collection of personal identifiers.

Conclusion

Addressing ethical challenges that researchers face when conducting PAC research with adolescents requires guidance at the individual, institutional, community, and international levels. Overall, despite the documentation of challenges in the published literature, guidance on handling several of these ethics challenges is sparse. We encourage further research to clarify the identified challenges and support the development of formal guidance in this area.

Untroubling abortion: A discourse analysis of women's accounts

In this paper, I highlight key differences between a discourse analytic approach to women's accounts of abortion and that taken by the growing body of research that seeks to explore and measure women's experiences of abortion stigma. Drawing on critical analyses of the conceptualisation of stigma in other fields of healthcare, I suggest that research on abortion stigma often risks reifying it by failing to consider how identities are continually re-negotiated through language-use. In contrast, by attending to language as a form of social action, discursive psychology makes it possible to emphasise speakers' capacity to construct "untroubled" (i.e. non-stigmatised) identities, while acknowledging that this process is constrained by the contexts in which talk takes place. My analysis applies these insights to interviews with women concerning their experiences of having an abortion in England. I highlight three forms of discursive work through which women navigate "trouble" in their accounts of abortion, and critically consider the resources available for meaning-making within this particular context of talk. In doing so, I aim to provoke reflection about the discursive frameworks through which women's accounts of abortion are solicited and explored.

Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States

OBJECTIVE

To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

METHOD

Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

RESULTS

After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30-1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13-1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0-11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

CONCLUSION

Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

Psychosocial factors and pre-abortion psychological health: The significance of stigma

RATIONALE

Most research in mental health and abortion has examined factors associated with post-abortion psychological health. However, research that follows women from before to after their abortion consistently finds that depressive, anxiety, and stress symptoms are highest just before an abortion compared to any time afterwards.

OBJECTIVE

This finding suggests that studies investigating psychosocial factors related to pre-abortion mental health are warranted.

METHODS

The current study uses data from 353 women seeking abortions at three community reproductive health clinics to examine predictors of pre-abortion psychological health. Drawing from three perspectives in the abortion and mental health literature, common risks, stress and coping, and sociocultural context, we conducted multivariable analyses to examine the contribution of important factors on depressive, anxiety, and stress symptoms just before an abortion, including sociodemographics, abortion characteristics, childhood adversities, recent adversities with an intimate partner, relationship context, future pregnancy desires, and perceived abortion stigma.

RESULTS

Childhood and partner adversities, including reproductive coercion, were associated with negative mental health symptoms, as was perceived abortion stigma. Before perceived abortion stigma was entered into the model, 18.6%, 20.7%, and 16.8% of the variance in depressive, anxiety, and stress symptoms respectively, was explained. Perceived abortion stigma explained an additional 13.2%, 9.7%, and 10.7% of the variance in depressive, anxiety, and stress symptoms pre-abortion.

CONCLUSION

This study, one of the first to focus on pre-abortion mental health as an outcome, suggests that addressing stigma among women seeking abortions may significantly lower their psychological distress.

Pathways Between Concealable Stigmatized Identities and Substance Misuse

Individuals with concealable stigmatized identities often possess no obviously devalued attributes, yet are at greater risk for problematic substance use compared to their privileged counterparts. We present a conceptual model, which proposes that identity-relevant content and characteristics have important implications for cognitive, affective, and behavioral consequences of stigma-related stress. In doing so, we synthesize stigma-related models from the extant literature and attempt to integrate these concepts with previous work detailing potential contributors to substance use behaviors specifically. Finally, we ask readers to consider the various ways in which the content and characteristics of an individual's stigmatized identity might combine with situational and additional individual difference factors to influence the likelihood of substance misuse.

Maternal mortality in rural south Ethiopia: outcomes of community-based birth registration by health extension workers

INTRODUCTION

Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia.

METHODS

In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke.

RESULTS

We registered 10,987 births (81·4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71·6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2·5% (282) at health centres, and 3·5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0·051) and the villages had no road access (946 vs. 410; p= 0·039). The validation helped to increase the registration coverage by 10% through feedback discussions.

CONCLUSION

It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.

"When you're in a crisis like that, you don't want people to know": mortgage strain, stigma, and mental health

OBJECTIVES

We analyzed experiences of stigmatization, concealment, and isolation among African American homeowners who were experiencing mortgage strain.

METHODS

We conducted semistructured interviews between March 2012 and May 2013 with 28 African American homeowners in a northeastern US city who were experiencing mortgage strain. We coded all of the transcripts and reviewed data for codes relating to stigma, sharing information, social support, social isolation, and the meaning of homeownership.

RESULTS

Our data showed that mortgage strain can be a concealable stigma. Participants internalized this stigma, expressing shame about their mortgage situation. Additionally, some participants anticipated that others would view them as less worthy given their mortgage trouble. In an effort to avoid stigmatization, many concealed their mortgage trouble, which often led to isolation. This stigmatization, concealment, and isolation seemed to contribute to participants' depression, anxiety, and emotional distress.

CONCLUSIONS

Stigma may exacerbate stress associated with mortgage strain and contribute to poor mental health, particularly among upwardly mobile African Americans who have overcome significant structural barriers to home ownership. Reducing stigma associated with mortgage strain may help to reduce the health consequences of this stressful life event.

Concealment of lung cancer diagnosis: prevalence and correlates

BACKGROUND

Lung cancer has a commonly understood behavioral etiology. Thus, lung cancer patients are often blamed for their illness and may seek to avoid this blame by concealing their diagnosis from others. This study sought to determine the prevalence of concealment and identify demographic, clinical, and psychosocial correlates of concealment among lung cancer patients.

METHODS

A sample of 117 lung cancer patients receiving chemotherapy for non-small cell or small cell lung cancer was recruited and completed self-report demographic questionnaires, a measure of diagnosis concealment designed and pilot tested for this study, and standard measures of psychosocial variables. Clinical factors were assessed via a medical chart review.

RESULTS

Thirty participants (26%) reported concealing their diagnosis in the previous month, most frequently from casual friends and close friends. Reported reasons for concealment largely reflected concern for others. Univariate analyses indicated that those who concealed their lung cancer diagnosis reported more internalized shame related to their illness and use of positive reappraisal as a coping strategy (ps ≤ 0.02). In addition, those who concealed were more likely to have used alcohol in the previous month and have a more recent recurrence, among those who had a recurrence (ps ≤ 0.04). Multivariate analyses indicated that internalized shame and use of positive reappraisal accounted for significant unique variance in concealment above and beyond that accounted for by use of alcohol (ps < 0.05).

CONCLUSIONS

Future research should aim to replicate and extend these findings with longitudinal designs to elucidate the directionality of the associations observed in this study.

"Discredited" Versus "Discreditable": Understanding How Shared and Unique Stigma Mechanisms Affect Psychological and Physical Health Disparities

In his classic treatise, Goffman (1963) delineates between people who are discredited-whose stigma is clearly known or visible-and people who are discreditable-whose stigma is unknown and can be concealable. To what extent has research in the past 50 years advanced Goffman's original ideas regarding the impact of concealability on stigma management strategies and outcomes? In the current article, we outline a framework that articulates how stigma can "get under the skin" in order to lead to psychological and physical health disparities. Further, we consider when and to what degree concealability moderates these effects, creating divergent outcomes for the discredited and discreditable. Does the stigmatized individual assume his differentness is known about already or is evident on the spot, or does he assume it is neither known about by those present nor immediately perceivable by them? In the first case one deals with the plight of the discredited, in the second with that of the discreditable. This is an important difference.- Goffman (1963, p. 4).

"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal

Background

Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers’ views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care.

Methods

To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data.

Results

Overall, participants had positive views of abortion legalization – many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment.

Conclusions

Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

Mental health consequences of unintended childlessness and unplanned births: gender differences and life course dynamics

The discordance between fertility intentions and outcomes may be associated with mental health in the general population. This requires data directly linking individuals' fertility intentions with their outcomes. This study brings together two streams of research on fertility and psychological distress to examine whether unintended childlessness and unplanned births are associated with psychological distress, compared with intended childlessness and planned births. We also examine whether unintended childlessness and unplanned births are differently associated with distress at two stages of the individuals' life course: in early and late 30s. As women are more directly affected by the decline in fertility with age and the experience of motherhood is more central to women's identity, we also examined gender differences in these associations. Thus, we examined the association between four possible fertility events (planned and unplanned births, intended and unintended childlessness) and psychological distress of men and women, at two different stages over the life course (early and late 30s). We used longitudinal data from the US National Longitudinal Study of Youth 1979 (N=2524) to link individuals' fertility intentions and outcomes to evaluate the association of depressive symptoms (CES-D) with four possible fertility events occurring in two-year intervals, for men and women separately. Contrary to our first hypothesis, unintended childlessness and unplanned births were not associated with psychological distress for women. Among men, only unplanned births in their early 30s were associated with increases in psychological distress. We did not find support for our second hypothesis that unintended childlessness and unplanned births have a different association with psychological distress for men and women and as a function of the stage of life. These findings are discussed in the context of previous literature in this area.

Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence

In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress--explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.