Restrictive, often punitive, abortion laws and policies—such as mandating that all second-trimester abortions be performed in a hospital, limitations on the pool of abortion providers, required ultrasound viewing, and required waiting times before an abortion—stigmatize those who seek and those who provide abortion services. This abortion-related stigma produces a variety of stigmatic and psychological harms by creating and perpetuating feelings of shame and psychological stress about abortion and imposing the government’s disapproval of abortion at every point in the delivery of services.1–3
ABORTION-RELATED STIGMA
Abortion-related stigma is created by cultural norms and reinforced by policies that harm those who provide and those who receive abortions. Abortion-related stigma has been defined as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood.”4(p628) This is the case even though we know from national statistics that abortion is an extremely common gynecological experience among American women, with approximately 25% of women having an abortion in their lifetime.5 Social norms that purport the exceptionality of abortion label those who seek abortion as deviants who are “promiscuous, sinful, selfish, dirty, irresponsible, heartless or murderous.”4(p629) Abortion can be seen as violating traditional standards of womanhood, motherhood, and sexual purity. Overt discrimination routinely occurs when those who seek abortion services are denied access to accurate information and treatment and are subject to punishment, including shame, endangerment of job or socioeconomic opportunities, and rejection in their communities.3,4
STIGMA CODIFIED INTO LAW
Abortion-related legislative actions, informed by unfounded negative characteristics or stereotypes related to abortion services and those who access these services, exacerbate, reinforce, and perpetuate stigmatization at an institutional level. For example, abortion-related laws build on the misconceptions that those who seek abortions are irresponsible or selfish and on the inaccurate stereotype that abortion is dangerous or unsafe. The stigmatized then suffer negative social and health outcomes, in part through experiences of prejudice and discrimination, which create daily stress and psychosocial distress that can interfere with physical and mental well-being.3
This structural stigma can grow through inequitable laws and policies, perpetuating discrimination by actors who react to the society-level stigmatization of a condition. Furthermore, public policy can activate a stereotype by making an association between a group and a behavior or reminding people about negative associations they may already hold about that group, such as those seeking or providing abortion services. People’s evaluations are misinformed by the stereotypes or stigma communicated through legal messaging that reinforces the relationship between a particular policy (e.g., mandatory ultrasounds) and a particular group (e.g., those seeking abortion services). In other words, laws, as well as the public debate of these laws, campaigns, and news coverage relating to the passage of stigmatizing policies, can increase negative attitudes toward discredited groups. Thus, laws and policies can exacerbate abortion-related stigma and discrimination experienced on the individual level.
EFFECTS OF ABORTION STIGMA ON HEALTH
Abortion stigma encourages members of society to shame those who seek abortion and fosters fear and psychological stress in patients who perceive this stigma. Abortion itself is not associated with an increased risk of any physical or mental health issues, but experiences and fears of abortion-related stigma can result in lower self-efficacy, reduced perceptions of social support to help with abortion decision-making, increased use of denial and avoidance coping techniques, and avoidance of needed services.1,3,4 This can include fewer people seeking reproductive health services because of fear of interpersonal and societal-level persecution and judgment. These represent devastating health consequences for people who experience stigma because of their abortion.
EXAMPLE OF ABORTION-RELATED STIGMA IN ALABAMA
In a study on young Alabama women’s perceptions of reproductive options, participants described the inevitability of parenting; participants perceived parenting as the only acceptable option when faced with an unintended pregnancy.6 This perception resulted from opinions that abortion was a shameful and socially unacceptable option, as well as the difficulties in accessing abortion caused by restrictive state laws. Stigma about abortion caused women to hide their abortion history from family members, community members, and health care providers. Another study found that abortion stigma in Alabama made it difficult for women to disclose to others why they needed help with transportation or time off from work to be able to visit distant clinics for abortion counseling and services.7
MISINFORMATION AND LEGAL RESTRICTIONS
Restrictive policies, such as those enacted in Alabama, are reflections of society’s ideologies and therefore reinforce stigmatizing norms. Abortion stigma is codified in laws that limit abortion access and promote the provision of inaccurate information and thus is embedded across educational, legal, health, and welfare systems. The effects of this structural stigma are compounded by poverty and other socioeconomic deficits. Laws that single out abortion facilities and regulate them differently (more stringently) than other outpatient clinics, contribute to the exceptionality of abortion and convey the idea that abortion is different from other medical services. Such laws constrain abortion access and invoke and perpetuate inaccurate perceptions that abortion is dangerous and morally wrong, creating the belief that those who have abortions are deviating from appropriate behavior. The resulting stigma negatively affects both patients and providers.2
Specifically, informed consent requirements often expose the patient to such things as misleading information about physical or psychological risks of abortion services, fetal imagery designed to reflect greater development than is accurate, references to the patient as “the mother,” and making the patient listen to fetal heart tones. These requirements create the inaccurate perception that abortion is a major medical procedure and that the fetus is viable, even in circumstances when it is not. These tactics obscure the pregnant person from view, decontextualize the fetus, overstate the fetus’s independence, and ignore the pregnant person’s circumstances and preferences. Restrictive abortion laws threaten a patient’s reproductive autonomy: the ability to make decisions based on one’s personal considerations and free from external forces, including the judgment of other people and institutions. By making abortion services logistically and financially difficult to access, such laws and policies fundamentally convey the notion that pregnant individuals need to be protected from making the wrong decision.
CONCLUSIONS
Abortion laws being enacted across the United States—such as imposing stringent requirements on facilities offering five or more first-trimester abortions per month, mandating all second-trimester abortions be performed in a hospital, limiting the pool of clinicians, requiring at least 24 hours before a procedure, requiring that health care providers perform an ultrasound, giving patients state-mandated verbal information, offering printed materials that are in part inaccurate or misleading, and criminalizing violations of the statutory requirements—create and reinforce the unfounded and unsubstantiated exceptionality of abortion, the perception that abortion is morally wrong, and the shaming of abortion patients and providers.1,2,4
These laws treat patients as fundamentally suspect by promoting the inaccurate stereotype that those who seek abortion services are morally deviant and incompetent decision makers. The resulting stigma increases the risk of poor psychological and physical health outcomes among pregnant individuals and stigmatizes, devalues, and professionally harms abortion providers.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
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