Week 6 Assignment 1

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Sociology Compass 9/5 (2015): 365–378, 10.1111/soc4.12256

Abortion Counselling in Britain: Understanding the Controversy

Lesley Hoggart* Health and Social Care, The Open University

Abstract This article reviews literature from a number of disciplines in order to provide an explanation of the political controversy attached to the provision of abortion counselling. It will show how this is an area of health policy debate in which women’s reproductive bodies have become a setting for political strug- gle. The issue of abortion counselling in Britain has undergone a number of discursive shifts in response to political manoeuvring and changing socio-legal framing of abortion. In particular, the article shows how much of the controversial reframing of abortion counselling was a tactical shift by political actors opposed to abortion per se, and this work is critiqued for not contextualising abortion. The article then focuses on women’s abortion experiences and discusses research that shows how women’s decision-making processes, and responses to an abortion, are related to gendered socio-cultural contexts: the extent to which women having an abortion feel they have transgressed societal norms and values, for example, is likely to affect their abortion experiences. Finally, it is suggested that providing a non-judgemental context, and challenging negative discourses on abortion, may be the most effective way of minimising the possibility of negative emotions.

Introduction

This article examines the issue of abortion counselling as a site of policy debate, in which women’s reproductive bodies have become a setting of political struggle. In seeking to understand why a seemingly straightforward subject – whether women undergoing an abortion should have access to counselling services – has become so contentious, it is necessary to con- sider a wide range of other issues. An over-arching requirement is to consider how the debate is socio-culturally located. This means understanding that policy debates on abortion counsel- ling are conceptualised differently within different socio-legal frameworks; within gendered social norms; and within contentious political discourses. Even the phrase itself – abortion counselling – has been subject to a number of discursive shifts and invested with multiple mean- ings which are complex and malleable. Above all, as this paper will show, different strands of academic debate around abortion counselling customarily proceed from particular political positioning, and with an eye to the political implications of research interpretations. There is an undeniable relationship between political beliefs on abortion and intellectual framing on the issue of abortion counselling. These broader sociological issues frame this paper, which focuses on Britain1 as a case study explicating the relationship between socio-cultural contexts and different politics, policies and practices. Britain, in recent years, has experienced repeated flurries of political debate and activity

around the issue of pre-abortion counselling. Between October 2006 and June 2007, two Ten Minute Rule Bills that proposed mandatory counselling were rejected by the British Parliament, and in 2012, the MPs Frank Field and Nadine Dorries proposed amendments to the National Health Service (NHS) and Social Care Bill 2011 which would have removed

counselling services from abortion providers and obliged women to receive counselling from ‘independent’ bodies before an abortion.2

Abortion counselling as an issue is worthy of exploration because, as the paper also sets out, developments in this area affect abortion provision and thus have an effect upon women under- going an abortion. Although a straightforward policy question would address what provision should look like in this area, such questions have always been bound up in wider political debates about the morality of abortion and views on its legal status. In academia, important contributions to the debate, from sociology, have come from Ellie Lee, who has consistently shown how sociological constructions – of women, of abortion and of abortion providers – have informed the legal regulation of abortion in Britain (Lee 1998, 2003a,b, 2004). Kristin Luker (1984, 1996) and Rosalind Petchesky (1986) have pioneered sociological work in this area internationally. Although fundamentally an issue of concern to political sociologists, many more disciplines are involved in contributing towards literature of relevance to the issue of abortion counselling, including important contributions from psychology (Boyle 1997; MacLeod 2011); law ( Jackson 2001; Sheldon 1997); and policy research (Allen 1985; Hoggart 2003, 2012; Rowlands 2008). This paper reviews three areas of literature, all of which straddle these disciplines. Firstly, it considers how policy and health-focused literature contributes towards understandings about what is meant by counselling in the context of abortion. Secondly, it looks at literature that has sought to explain, and engage with, why counselling came to feature as part of what Rickie Solinger (1998) has termed ‘Abortion Wars’. Finally, it will look at a body of literature that sheds light on the provision of abortion counselling, from the perspectives of women who have abortions.

What is meant by counselling?

The legal framework for abortion in Britain is the 1967 Abortion Act. This Act, as amended by the Human Fertilisation and Embryology Act 1990, permits abortion up to 24weeks in specific circumstances (when two doctors agree that continuing with the pregnancy would be more harmful to the physical or mental health of the pregnant woman or any existing children of her family than if the pregnancy was aborted). After 24weeks, an abortion is permitted if it is necessary to save the woman’s life; it will prevent grave, permanent injury to the physical or mental health of the pregnant woman; or there is a substantial risk that if the child were born, it would suffer from serious physical or mental anomalies.3 In law, at no gestational point do women have the right to an abortion on request. However, as Lee (2003b) has noted, a ‘socio-legal gap’ gradually emerged between law and practice such that the wishes of women came to be prioritised. This is evident by reviewing the British government’s health information website, NHS Choices, which simply lists one of the reasons that a woman might decide to have an abortion as ‘personal circumstances’.4 This unresolved tension between law and practice, though, means that abortion practice as it has developed does not have a firm legal foundation and may be vulnerable to changing political circumstances. It also legitimises the attempts by those interest groups who are opposed to abortion to claim that the law is f louted (Lee 2003b). In Britain, abortion counselling is an area of abortion practice that has been developed as part

of abortion services. It is not required by law and is not legally regulated. There is, accordingly, significant room for disparate and shifting definitions of abortion counselling. Nevertheless, a body of research has studied these issues and clarified both what women should expect with respect to abortion counselling and how to define and develop these services. Following the 1967 Abortion Act, a Committee on the Working of the Abortion Act (the

Lane Committee) was set up by the government in order to examine the workings of the Act. The conclusions of the Lane Committee (Lane 1974), as well as a paper authored by

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one Lane commissioner (Cheetham 1977), revealed considerable confusion around what was meant by abortion counselling. The report noted uncertainties about the objectives and pur- poses of counselling, and then offered a broad definition: counselling was described as the pro- vision of an opportunity for women to discuss their situation and to obtain information, explanations and advice. The literature has noted that the Lane Committee was particularly concerned to ensure that every effort should be made to provide women equality of access to abortion within the NHS, at a time when some women were being turned away arbitrarily (Wivel 1998). As abortion services were being developed in the 1970s, abortion counselling was thus primarily envisaged in the context of ensuring that all women who are considering an abortion are provided with enough information with which to make an informed decision, that this should be free from pressure from other people, and that equality of access should be ensured (Lee 2003b). In the 1980s, the Department of Health and Social Security commissioned a national evalu-

ation of Counselling services for sterilisation, vasectomy, and termination of pregnancy. To date, the only study solely on these issues, it was a large multi-stranded project with a clear focus on the expe- riences of service users on the counselling they had received, and the extent to which they felt they required counselling (Allen 1985). This focus marked a shift towards a multifaceted under- standing of counselling that moved beyond the Lane-based consensus of ensuring informed consent and equality of access. The research found considerable variance about what was meant by counselling as a specific activity and pointed to an important distinction between the role of abortion providers in ensuring that women were making an ‘informed decision’ to proceed, or otherwise, with an abortion; and therapeutic counselling which may be necessary for women who are ambivalent about their decision. The first discussion is always necessary, whilst thera- peutic counselling may, or may not, be needed or appreciated. Indeed, Allen also reported: ‘Many women thought that abortion should be easier and quicker to get, and that counselling should be available for those who wanted it but not overdone’ (Allen 1985: 342). Allen is here drawing attention to one of the most notable findings in the study: that many women felt they were being over-counselled about a decision they had already made. A large number of women talked about making their own decision after considering their own circumstances and not needing to talk to anyone in the process. There have been no further large scale studies of abortion counselling provision in the UK,

though other studies and policy developments have led to further refinement of what is understood by counselling. Myra Hunter presented a model of counselling for obstetrics and gynaecology (including abortion) in which she distinguished between providing information and emotional support to all women and providing specific support to women who are distressed for any reason (Hunter 1994). Similarly, Jane Read (1995) considered different types of counselling in abortion: information counselling, implications counselling, support counsel- ling and therapeutic counselling; and also suggested similar needs for women undergoing abortion to those seeking assisted conception. Neither of these important books, written primarily for practitioners by practicing therapists, single out women who have an abortion as being in particular need of counselling. What they are clear about is that if some women need therapeutic counselling, this is a distinctive need that should not be confused with information and general support that all women should expect from all these services, and this reflected a more nuanced understanding than the Lane consensus. With respect to abortion research more generally, this has simultaneously helped shape, and

responded to, shifts in understandings, and practices, of abortion counselling. In a review of relevant literature from 1967 onwards, Rowlands (2008) sought to identify research studies (internationally) with some findings of relevance to the issue of abortion counselling. In his systematic review, he noted that the term ‘counselling’ is used widely and indiscriminately

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and is frequently used to describe the activity of simply providing information. He drew attention to the need to distinguish between different types of counselling ranging from general support and information (as proposed by Lane) through to therapeutic counselling. He also noted, however, that much of the research focuses on what has been described as ‘decision counselling’, which has often been proposed as counselling in a more therapeutic sense. Many of the papers in the review introduced the notion of ambivalence to studies on abortion decision-making, a concept that will be further explored later in this paper. Noting that whilst ‘hard evidence’ for the beneficial effects of such decision counselling is rare, and that there was no evidence that this should be a mandatory service for all women, Rowlands also observed that a general agreement emerged from the 1970s onwards that this service, seeking to assist those with difficulties making decision about the outcome of a pregnancy, should be provided. This is indeed the direction in which abortion policy and provision has moved, in Britain, a direction which illustrates a sometimes fraught, but nonetheless significant, relationship between research and policy developments. The policy approach is evident in guidelines that have been generated specifically for

abortion service provision. The RCOG (Royal College of Obstetricians & Gynaecologists) collates evidence and sets standards for care in abortion (including counselling requirements). The RCOG’s Guidelines, first published in 2000, (RCOG 2011) distinguish between three domains: the first is information needs as discussed earlier (the need for clinicians to have accurate knowledge about medical complications associated with abortion, to ensure that dis- cussion with woman can allow for valid consent to be given by them); the second is to state that all women should be offered the opportunity to discuss their decision with a non-directive counsellor, and/or clinician; and thirdly, it recommended that additional counselling be made available for women who request it. The Department of Health regulates counselling provision in all abortion units through

Required Standard Operating Principles (RSOPs) for termination of pregnancy services (DoH 2013a). These draw on the RCOG Guidelines and state (p. 20) that, ‘All women requesting an abortion should be offered the opportunity to discuss their options and choices with a trained counsellor and this offer should be repeated at every stage of the care pathway. Post abortion counselling should also be available for those women who require it’. Indepen- dent sector agencies, primarily the British Pregnancy Advisory Service (bpas) and Marie Stopes International (MSI), have increasingly provided the majority of NHS funded procedures (Lee 2005; Lee and Ingham 2010). At both these agencies, two types of counselling are available: all women are offered ‘decision counselling’ (either by telephone or in-person) as part of their advice and information session, and therapeutic counselling is made available for any woman who may request it. This sector has developed a particular category of staff, the ‘admin counsellor’ who (together with medical personnel) has responsibility for information provision and ‘decision counselling’. Women who need it have access to staff trained and specialised in therapeutic counselling (Lee 2003b). This overview has shown that (apart from those opposed to abortion) a policy consensus has

emerged, and that this consensus does inform abortion providers: therapeutic counselling for women considering an abortion should be available for those women who may need it, but this should not to be confused with discussions that facilitate informed consent, or with discussions designed to establish women’s comfort with their decision (sometimes called options, or decision, counselling). Although these latter discussions may be facilitated by a trained counsel- lor, this is not essential, and they do not constitute therapeutic counselling. Decision counselling is potentially confusing, as for the most part, it will not involve therapeutic counselling; but, if women are experiencing difficulties with abortion decision-making, for any of a number of what could be complex reasons, then therapeutic counselling should be available. As will be

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shown later, the research on women’s abortion decision-making suggests that such counselling would almost certainly not be needed by the majority of women.

Why did abortion counselling emerge as a controversial issue?

Given that the purpose and scope of abortion counselling has been both expanded and clarified since the Lane Committee, and detailed guidance exists, why does it regularly emerge in Britain as a controversial issue? An exploration of the literature on the politics of abortion and on debates around ‘Post-Abortion Syndrome’ (PAS) can shed light on this conundrum. Although these are international issues, and this literature is not confined to Britain, this paper will continue to apply the research to the British case study. Following the 1967 Abortion Act, anti-abortion organisations began campaigning against

abortion provision in Britain, at first concentrating on campaigns supporting legislation drafted to restrict existing provision. A series of Private Members Bills, all of which would have seriously curtailed women’s right to an abortion in one way or another, were introduced in the 1970s and 1980s. All prompted vociferous and confrontational political campaigns for and against the legislation; all were defeated (Hoggart 2000). During this period, organisations opposed to abortion, such as SPUC (Society for the Protection for the Unborn Child) and then LIFE, very much focused on the right to life of what they conceptualised as the ‘innocent baby’, and abortion politics was dominated by a discourse of competing rights, with campaigners in favour of retaining abortion rights campaigning in favour of ‘a woman’s right to choose’ (Himmelweit 1988; Hoggart 2003). The oppositional viewpoints in this conflict are generally referred to in academic literature on abortion as pro-choice and anti-choice (Cannold 2002). A number of academics have analysed how anti-choice activists were obliged to rethink their

strategy when it became clear that the (‘innocent baby’) foetal discourse was not effective (Cannold 2002; Lee 2001, 2003a,b). Throughout the 1970s and into the 1980s, opinion polls had indicated that a majority of the population supported liberal abortion law, and it became increasingly clear that large numbers of people were not going to be persuaded by appeals based on positioning women seeking an abortion as immoral murderers. So, from the mid-1980s, a new anti-choice strategy, characterised by Leslie Cannold as a ‘women-centred strategy’, was developed: ‘a key task of the anti-choice women-centred strategy is to replace the fetus with the guilt-ridden, self-hating, grief-stricken, victimised and finger-pointing “woman hurt by abortion” as the summarising image of what is wrong with abortion’ (Cannold 2002, p. 173). This strategy not only constructed abortion as an innately traumatic event that may cause psychological damage, but portrayed women seeking an abortion as inherently vulnerable and susceptible to duress. This was a conscious and significant tactical and discursive shift amongst activists campaigning to restrict abortion. Recent debates on abortion counselling need to be understood in the light of these political developments. The research evidence on these issues will now be examined in a little more detail. The argument for PAS, and its diagnostic criteria, has been traced by Ellie Lee (2001) to the

work of an American, Vincent Rue, who proposed it as a form of post-traumatic stress disorder (PTSD) (Rue 1995). More recently, the mantle has been taken up by Priscilla Coleman. Coleman’s claims that quantitative research has shown an increased risk of mental health prob- lems after abortion were published in The British Journal of Psychiatry (Coleman 2011) but have since been widely discredited.5 These discussions are relevant to the pre-abortion counselling debate because, as noted earlier, some anti-choice activists made a discursive shift to focus on the possibility of post-abortion psychological distress, and this incorporated the argument that women will suffer if they have been insufficiently ‘counselled’ about the negative impact of abortion. Indeed, Coleman’s paper was explicitly referred to by Nadine Dorries in the House

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of Commons when she was seeking to introduce additional abortion counselling requirements.6

This conceptualisation of counselling is quite different from the decision counselling proposed in the health service research discussed earlier, in which there is a strong emphasis on the need for the counselling to be non-judgemental. An extra stimulus for anti-choice activists in Britain to adopt this strategy is that suggesting that abortion causes psychological damage also challenges one of the main criteria for abortion: continuing with the pregnancy would involve a greater risk to the woman’s physical or mental health than ending the pregnancy. There is now a large amount of international literature discussing the possible negative

psychological consequences of abortion in which pro-choice academics have devoted a significant amount of energy to critically analysing the claims that abortion causes mental health problems (Steinberg and Finer 2011). There are two main issues to note about this discussion. First, there is a lack of robust research evidence supporting the concept of PAS. As noted by a panel commissioned by the American Psychological Association to investigate the psychological consequences of abortion, the majority of studies suffer from methodological problems (Major et al. 2009). This is because it is virtually impossible to compare a cohort of women who have an abortion to a valid comparison group (Steinberg and Russo 2008).7 Second, the research that purportedly demonstrates PAS has been widely discredited for not taking into consideration the social, cultural and health care contexts within which an abortion takes place, as well as events confounded with abortion (sexual abuse, for example) that may themselves be associated with negative mental health outcomes (Dagg 1991; Lee 2003a; Steinberg and Russo 2008). In 2008, a review of the literature (Charles et al. 2008) concluded that the claim that abortion leads to mental health problems had been discredited by high quality research. More recently, the research on abortion and mental health has also been systematically reviewed for the Academy of Medical Royal Colleges, which concluded that there was no difference in mental health problems between women with unwanted pregnancies who gave birth and those who had an abortion (AMRC 2011). Although this may appear to be a purely academic debate, critiques of PAS have demon-

strated how anti-abortion bias has affected the way in which data are interpreted. Dervious and Russo (2000) show how in research that claims to identify PAS, any negative mental health outcomes that may be identified in women following an abortion are: firstly, mis-labelled as psychological sequelae when they are correlates; secondly, attributed to the abortion, rather than an unwanted pregnancy; and, thirdly, taken out of context. In addition, the anti-choice call for abortion counselling, drawing on the concepts ‘post-abortion syndrome’ and ‘abortion trauma’, not only elides pre- and post-abortion counselling, but also blurs the distinction between information provision and obtaining informed consent, and counselling. This particular focus of much pro-choice research and scholarship has thus been reactive,

making it difficult for researchers to focus on what women actually want. Further, there is a notable absence of a clear consensus on the most appropriate framework to deploy when researching women’s abortion experiences. As Mary Boyle (2000) has pointed out, the heated debates that take place about abortion, often from polarised positions, make it politically diffi- cult for researchers to explore the complexity of women’s abortion emotions, behaviour and needs. Indeed, she cautions against research that is focused upon whether women do, or do not, experience negative outcomes following an abortion or whether or not women seeking an abortion could be described as vulnerable, on the grounds that this keeps research within an agenda which focuses on abortion’s intrinsic potential to harm women (Boyle 2002). In Britain, this is an especially pertinent point because, as Lee (2003b) has pointed out, the justifi- cation of legal abortion enshrined in the 1967 Act is very much based on the construction of women as psychologically vulnerable victims. So there are a number of factors that discourage pro-choice researchers from dwelling on abortion and emotions. Others, however, have

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pointed out that the polarisation can cause pro-choice researchers to deny any possibility of negative or ambivalent emotions following an abortion, suggesting that such a denial of some women’s feelings may not be welcomed by women themselves (Cannold 2002). More recently, there has been greater willingness to tackle such issues, often within the context of theorising abortion-related stigma, and with an underlying assumption that an exploration of the full range of post-abortion emotions does not, of necessity, lead to an anti-choice interpretation of the research (Cockrill and Nack 2013; Hoggart 2012; Quinn and Chaudoir 2009). Although such considerations have made research challenging, there has been interest

amongst pro-choice researchers and abortion providers in examining women’s abortion experiences. From this research, it is possible to analyse the issue of abortion counselling from the perspectives of women who have abortions.

Women’s abortion experiences: who needs counselling?

Although few research studies have focused specifically on counselling, there is a body of research that has considered women’s abortion decision-making, abortion experiences and their expressed needs. The socio-legal context outlined above, in which understandings of abortion counselling have become more nuanced over the years, and yet are still not legally defined or regulated, forms the backdrop to the research in Britain. A particularly important theme in research on women’s abortion experiences is the value

women place on providers being clearly non-judgemental. In particular, information provision and staff attitudes (kindliness and acting in a manner that reduces women’s feelings of anxiety and isolation) feature in women’s reports (Harden and Ogden 1999; Lee et al. 2004). Rowlands (2008) also points out that the research indicates that women value being given clear information about abortion procedures at the pre-abortion consultation, and a recent study has shown that women value an uncomplicated referral process (Brown 2013). Research on abortion decision-making has shown that women take a range of issues into

consideration and generally make their decision based on their own individual circumstances at a particular moment in time (Purcell et al. 2014; Rowlands 2008). It has been noted also that the most usual experience is where women discuss their situation with friends, parents and family members and have already made their decision, before they approach a medical professional, or abortion provider (Brown 2013; Kumar et al. 2004). It has been argued that the research evidence indicates that whilst women may be distressed when faced with an unwanted pregnancy, more are comfortable with their decision that is often assumed in public debate (Boyle 2000; Hadley 1996), thus echoing findings of Allen’s (1985) counselling study. Another area where there is some agreement is in the recognition that it is women who may

be ambivalent about their decision who are most likely to express a need for therapeutic counselling. Research has shown that ambivalent women are at higher risk of poor psycholog- ical outcomes than non-ambivalent women (Ashton 1980; Cameron 2010; Hare and Heywood 1981). And Rowlands’ (2008) international review points out that most studies have shown that ambivalence has been shown to be a predictor of poor outcomes, but he is careful to point out that ‘feelings of ambivalence are an indication that abortion has a price, which implies that it is a more or less painful solution to an unwanted pregnancy’ (Rowlands 2008: 176). As we have seen, this does not mean that the abortion itself has caused poor psychological outcomes: abor- tion needs to be compared with continuation of pregnancy for this case to be made. (Kirkman et al. 2009) also conducted a review of the literature on reasons women give for an abortion and concluded that ambivalence was evident, and abortion was chosen because continuing with the pregnancy was assessed by the women as having adverse effects on their own lives and the lives of significant others. Purcell et al. (2014) have characterised the ambivalence they found in their

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study as women struggling with a dual candidacy: they are candidates for abortion and they are also candidates for motherhood, and sometimes this is a difficult decision; in this study, despite ambivalence, the women were comfortable that they had made the right decision for them- selves. The literature on ambivalence indicates that women who are unsure of their decision may need extra time and help, and maybe sometimes therapeutic counselling. The previous sec- tion has shown that official guidance and abortion providers have taken this into consideration. There is another body of work, however, with a pro-choice perspective, which suggests that

the extent of women’s need for therapeutic counselling may have been underestimated (Ashurst and Hall 1989; Dana 1987; Walker 1990). This work can be traced back to feminist approaches to counselling offered by the Women’s Therapy Centre during the 1980s and 1990s. The Cen- tre viewed therapeutic counselling to be a necessary intervention that enabled feelings surround abortion to be addressed (Dana 1987). It was also argued that abortion can be experienced as part of a process of psychological maturation, and counselling can help in this respect. Some more recent contributions from the counselling profession have echoed the position developed by feminists regarding the role that therapeutic counselling could play in pushing abortion towards being a positive, rather than a negative, experience (Brien and Fairbairn 1996; Hodson 2002).8

As there have been no recent studies on the provision and content of abortion counselling, it is not possible to judge whether this particular focus has influenced the content, and affect, of therapeutic counselling. There is, however, research evidence to support the claim that abortion can be a positive experience, showing how making such an important decision, and exercising autonomy, can - in and of itself – empower women (Harden and Ogden 1999). This research suggests that positive experiences associated with abortion, such as non-judgemental treatment, or feeling empowered, can contribute towards positive feelings. Conversely, an association can be seen between negative abortion experiences, whatever may cause the negativity, and negative emotions (Boyle and McEvoy 1998). Negative emotions clearly can make the need for therapeutic counselling more likely. The socio-cultural context within which abortion takes place is therefore of central importance to the debate on abortion counselling. With this in mind, it is worth pointing out that although abortion services have improved considerably in Britain since the 1970s, the political discourse has lagged behind. National statistics show that over the years, there has been an increase in NHS funded abor-

tions provided by the independent sector; and that an increasing proportion of these abortions are carried out earlier in pregnancy.9 Such improvements have been facilitated by sexual health policy developments going back to the formulation of a National Strategy for Sexual Health and HIV (DoH 2001), a strategy that sought to improve access to abortion services and has recently been updated (DoH 2013b). However, as has been pointed out, these developments can be characterised as ‘abortion pragmatism’ (Lee 2013): that is, they are based on an understanding that abortion needs to be tolerated in order to prevent ‘undesirable’ childbearing – particularly amongst teenagers. Within this agenda, it is still possible to frame abortion as morally undesir- able: by proposing that contraceptive services might be improved on the basis of reducing the abortion rate, for example (Hoggart 2012). Such framing does not challenge what has been termed the ‘awfulisation’ of abortion (Hadley 1996), and ‘abortion negativity’ (Lee et al. 2004) and can have an impact on services. It has recently been claimed by a leading abortion provider that the political environment in Britain makes it difficult to press for significant improvements in abortion care (Furedi 2014). In addition, some research has suggested that ‘abortion negativity’ can contribute towards abortion-seeking women experiencing ambiva- lence pre- and post-abortion (Rowlands 2008). Such negativity is also an important part of a cultural context which can engender post-abortion regret for some women (Hoggart 2012). Some studies have shown how abortion providers may play a role in differentially constructing the legitimacy of abortions for different ‘types’ of women (Benyon-Jones 2013), whilst others

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have argued that providers themselves are subject to stigma and that the public discourse on abortion prevents them from challenging this stigma (Harris et al. 2013). Comparative analysis has also shown how women’s cultural affiliations and beliefs have an

impact on their emotional experiences and post-termination feelings (Bennett 2001; Kero et al. 2004; Lafaurie et al. 2005). When abortions take place within a context of moral disap- proval, this is likely to impact negatively upon women’s decision-making and experiences (Boyle and McEvoy 1998; Kumar et al. 2009). Relatively recently, researchers have begun to theorise one aspect of this negativity through an exploration of how abortion stigma is gener- ated in different contexts, what forms it takes and what the consequences are for women seeking an abortion. 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 woman- hood’ (Kumar et al. 2009: 628). As such, the theorisation of abortion stigma draws on work that has pointed to gender-specific meanings of abortion in relation to motherhood (Luker 1984), and other constructs of the ‘feminine’. As Cockrill and Nack (2013: 975) put it: ‘Abortion can signal multiple transgressions, including participating in sex without a desire for procreation, an unwillingness to become a mother, and/or a lack of maternal-fetal bonding’. These meanings vary according to different contexts. The stigma associated with women challenging particular gendered norms of sexuality and

motherhood through undergoing an abortion has been linked to the decision-making process as well as subsequent reproductive behaviour (Tsui 2011). Similarly, a recent UK study has shown non-disclosure of abortion is related to women’s perceptions of abortion as potentially stigmatising (Astbury-Ward et al. 2012). Norris et al. (2011) have stressed the importance of legal restrictions as an additional cause of abortion stigma, and this, of course, would vary according to different jurisdictions. In the UK, this is particularly relevant to Northern Ireland where legal restrictions result in thousands of women travelling, mainly to England and Wales, to obtain abortions, or purchasing the ‘abortion pill’ illegally.10 The moral conservatism, gendered social norms and religious legitimation associated with these restrictions have undoubtedly contributed towards especially negative experiences for women undergoing an abortion (Bloomer and Fegan 2014; Bloomer and O’Dowd 2014; Boyle 1997). Internationally, studies have found that abortion-related stigma can generate fear and guilt

and contribute to feelings of shame in moralistic societies. Although the stigma of abortion was perceived similarly in both legally liberal and restrictive settings, it was more evident in set- tings where abortion is highly restricted, and this affected disclosure (Cockrill and Nack 2013; Major and Gramzow 1999; Quinn and Chaudoir 2009; Schellenberg et al. 2011).

Discussion

This overview of the literature has shown how abortion counselling debates and controversies are fundamentally political, thus reflecting political divisions over abortion itself, and subject to change. This is evidently true on a number of different levels. In the first instance, the debate itself has its roots in the attempted construction of abortion as

inherently psychologically damaging and is most strongly articulated in the creative develop- ment of the notion of Post-Abortion Syndrome (PAS). This discourse positions women as vul- nerable, at risk of abortion-induced trauma, and therefore in need of therapeutic counselling. Legislative attempts to enforce pre-abortion counselling in which women can reflect upon their decision are not value-free but are linked to this anti-abortion agenda. However, as has also been shown, some pro-choice feminist practitioners and scholars have

suggested that counselling, both pre- and post-abortion, may be beneficial for women. This confluence of extremely dichotomous positions around the perceived need for abortion

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counselling calls for further exploration. Understanding that this is not a shared – but rather a contested – position is the starting point: those who support abortion and call for counselling do so from a perspective of helping abortion-seeking women (who may be experiencing emotional difficulties) make a decision that is right for them. Within this framing of counselling, some feminists have proposed therapeutic counselling in order that women can become empowered in their abortion process. By way of contrast, those who oppose abortion and call for counselling are anticipating that this may discourage women from having an abortion, or, at the very least, make it more difficult for them to do so. These are very different policy positions. Nevertheless, the confluence is striking. The two groupings are unlikely bedfellows, and this

only be understood by analysing political contexts and positionings. A further indication of the contentious political nature of these debates has been tensions within pro-choice research around the value of therapeutic counselling, and also concerning abortion-related emotions. Much of the research in this area is either concerned to dispute any connection between abortion and adverse psychological outcomes or reluctant to engage in the issue of emotions, particularly post-abortion emotions. This reluctance is largely due to an unwillingness to unwittingly contribute towards the ‘awfulisation’ of abortion. It is only comparatively recently, in a body of work emanating from the United States on abortion-related stigma, that women’s emotions are being fore-fronted in abortion research. There is less disagreement amongst supporters of abortion rights about decision counselling,

in all probability because such counselling is a central aspect of facilitating women’s reproductive choice. Taken as a whole, the research indicates that women considering abortion have a wide range of emotional responses to their situation. Many – possibly most –make their decision rapidly and are comfortable with their decision (Rowlands 2008). Some women may experi- ence ambivalence and decision counselling may be helpful to them. This review has also shown how women’s decision-making processes, and responses to an

abortion, are related to gendered socio-cultural contexts. In particular, the work on abortion- related stigma has shown how general shared features across different contexts – such as gen- dered norms of sexuality and motherhood – form a backdrop to abortion decision-making and experiences. Moving to another level, the research has shown how different contexts – taking into account, for example, socio-legal jurisdictions, the extent of moral conservatism, and different manifestations of abortion stigma – are likely to impact differentially on women considering an abortion. A final way in which politics intrudes is to hamper an evidence-based development of abor-

tion services through creating a political environment in which abortion policy and provision are contested terrain. Those opposed to abortion portray it as a moral wrong to be prevented, either by introducing a more restrictive legislative framework or making the process of obtaining an abortion more difficult, through imposing pre-abortion counselling, for example. Politicians and policy-makers who have embraced a pragmatic acceptance of abortion invariably find it difficult to avoid a moralistic framing of abortion, such that whilst necessary, it is nevertheless undesirable. It has been argued that medical advances in the abortion field, and a significant body of research on women’s abortion experiences, could lead to continual improvements in provision; yet, political tensions create a policy climate which is not conducive for the further development of evidence-based abortion services (Furedi 2014).

Conclusion

This paper has shown how debate around abortion counselling customarily proceeds from par- ticular political positioning. In Britain, following legalisation of abortion in limited circum- stances in 1967, early ‘abortion wars’ were concentrated on legislative attempts to amend the

374 Abortion Counselling

1967 Abortion Act in a restrictive manner. In parallel, those who were concerned to implement the Act focused on equality of access, and abortion counselling was viewed as a way of enabling women to access abortion. Moving into the 1980s and beyond, understandings of abortion counselling, however, changed and became a primary battleground. In the British Parliament, attempts to change current provision are consistently fronted by well-known anti-abortionists. Within the pro-choice, and also abortion provider, community, there is no overall consensus on the extent to which abortion counselling may be called for, though there is an acknowledge- ment of the importance of decision counselling to facilitate informed choice. Only those writing from an anti-choice perspective have disagreed with the general consensus that therapeutic counselling should be a voluntary activity openly available to all women. There currently is a pragmatic acceptance of the need for abortion in Britain, and the attempts

to generate causal theories about abortion engendering psychological damage have been thor- oughly discredited. It is probably no accident that recently research has begun to focus more sys- tematically on women’s experiences and needs, rather than simply responding to anti-choice discourses. In the United States, research on abortion-related stigma is leading to the develop- ment of creative interventions to combat stigma (Cockrill et al. 2013; Hessini 2014; Martin et al. 2014; Shellenberg et al. 2014). Although Britain is very different to the United States in terms of the pragmatic acceptance of abortion, the research still indicates that a societal level acceptance of the viewpoint that abortion is morally undesirable can adversely affect women. The research evidence leads logically to the suggestion that women’s abortion experiences might be improved by a determined effort to normalise, or de-stigmatise, abortion. Such developments would have the potential to make abortion decision-making less stressful and also decrease the likelihood of post-abortion distress, thus lessening the need for decision counselling or therapeutic counselling.

Short Biography

Dr. Lesley Hoggart is a Senior Lecturer in the Faculty of Health and Social Care at the Open University. She specialises in qualitative research and spent many years working in the qualita- tive research group at the Policy Studies Institute. Her research interests are focused on repro- ductive health, abortion policy and politics, teenage pregnancy and sexual health. Her publications include Feminist Campaigns for Birth Control and Abortion Rights in Britain, (The Edwin Mellen Press 2002); 2013. Hoggart, L. and Newton, V. ‘The contraceptive implant: understanding how experiencing side effects may challenge bodily control and lead to removal’, Reproductive Health Matters, 21(41) pp. 196-204; Hoggart, L., Newton, V. and Dickson, J. (2013) ‘“I think it depends on the body, with mine it didn’t work”: explaining young women’s decisions to request subdermal contraceptive implant removal.’ Contraception. Hoggart, L. (2012) ‘“I’m pregnant … what am I going to do?” An examination of value judge- ments and moral frameworks in teenage pregnancy decision making.’ Health, Risk and Society. 14:6 pp 533–549. Hoggart, L. and Phillips, J. (2011) ‘Teenage pregnancies that end in abortion: what can they tell us about contraceptive risk-taking?’ Journal of Family Planning and Reproductive Health Care, 37 pp. 97–102. She is currently convening an ESRC Seminar Series on Understanding the Young Sexual Body, in collaboration with King’s College London, Institute of Education, Anglia Ruskin University and Cardiff University.

Notes

* Correspondence address: Lesley Hoggart, Health and Social Care, The Open University, Walton Hall, Milton Keynes, MK7 6AA, UK. E-mail: Lesley.Hoggart@open.ac.uk

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1 This focus on Britain (England, Wales and Scotland), rather than the United Kingdom (England, Wales, Scotland and Northern Ireland), is because the 1967 Abortion Act specifically excludes Northern Ireland from its jurisdiction. 2 http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm110907/debtext/110907-0001.htm#11090754000002. 3 http://www.legislation.gov.uk/ukpga/1967/87/section/1. 4 http://www.nhs.uk/Conditions/Abortion/Pages/Introduction.aspx. 5 http://www.legislation.gov.uk/ukpga/1967/87/section/1. 6 http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm110907/debtext/110907-0001.htm#11090754001604. 7 The closest semi-experimental research possible on this topic is currently being undertaken by a team of researchers at the University of California, San Francisco. The Turnaway Study is comparing outcomes of women who have been denied an abortion because they are beyond the legal time limit to women who have obtained an abortion ‘just in time’, before reaching the limit. http://www.ansirh.org/research/turnaway.php. 8 See also recent papers available on the pro-choice forum website: Everett; Paterson and Ross. 9 www.parliament.uk/briefing-papers/sn04418.pdf. 10 http://www.theguardian.com/world/2013/mar/10/northern-irish-women-risk-jail-over-abortion-drug-use.

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