Abortion Stigma

Stigmatization is a deeply contextual process. It is related to the "disgrace of an individual through a particular attribute he or she holds in violation of social expectations". The attribute in question is abortion.

Kumar et al., (2009) in their article Conceptualising abortion stigma define abortion stigma as "a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of motherhood". While women who seek or have abortions no doubt face abortion stigma, so can abortion providers, friends, spouses and even pro-choice activists. All of these groups experience abortion stigma differently, and understanding their viewpoints may bring to light both causes and potential solutions to abortion stigma.

Characteristics of experience

Abortion stigma, and its consequences, is experienced in countries where abortion is highly restricted, as well as in countries with more liberal abortion laws. The stigma is more pronounced, however, in the former. Abortion stigma among those who have had an abortion are expected to follow an "implicit rule of secrecy", at least in the US, and due to this they often experience guilt and shame. Often, as long as women do not openly speak about their experience, they may consider themselves safe from stigma.

Africa

In Zambia, adolescent pregnancy rates are quite high. By age 19, 59.4% of females are either pregnant or have given birth.Many of these pregnancies are unwanted, and thus terminated, although exact numbers are difficult to estimate. According to Webb (2000) some of the main reasons for abortion are cited as "the desire to continue with school or if the boyfriend denies being the father". There is also mention of the fear of reaction of the parents. Furthermore, in interviews conducted by Webb (2000), some 15- to 19-year-old school boys claimed that "girls who abort are known as kaponya mafumo, ‘terminators of pregnancies’, and are stigmatized due to their ability to ‘infect’ others. This stigma is manifested in "not sharing utensils with this person or even greeting them." Hence, there is a drive to keep abortions secret, and thus self-induced and unsafe abortion rates are very high in Zambia.

In Ghana, due to religious beliefs or fear of side effects, women avoid using contraception. According to Tagoe-Darko (2013), "social stigma was a significant factor in pre-marital sex, unwanted teenage pregnancy and induced abortion", and so Ghanian women are forced to keep their abortion secret, in order to mitigate the effects of stigma. Some women use abortion as a means of family planning. Abortion is also considered murder and a sin in some circles, and so women experience guilt and grief if they decide to have an abortion.

Philippines

In the Philippines, many methods of unwanted pregnancy termination are used, including throwing oneself down the stairs, massage, and herbal remedies. Abortion is illegal in the Philippines, as well as highly stigmatized, so women resort to self-induced abortions. This may lead to "increased morbidity and mortality as a result." Since teenage and unintended pregnancy is highly stigmatized as well, resulting secrecy or lack of disclosure may increase the health risk of self-induced abortions for adolescents. Often "knowledge of abortifacients often came from informal sources, such as neighbors, friends, and relatives" as opposed to medical practitioners. Filipino participants in the focus groups and interviews that Gipson (2011) conducted often cited positioning in the womb and God's will as reasons for why a self-induced abortion was ineffective. Despite the fact that participants knew that unintended pregnancies were common, they expressed disapproval of the personal characteristics of those who had abortions. Abortion was considered a "double sin" for unmarried adolescents, since they engaged in pre-marital sex (which is frowned upon).

United States

In the United States, there have been drawbacks observed to the secrecy surrounding abortion. Women who keep their abortion secret are more likely to have adverse emotional outcomes, such as intrusive thoughts. It was found that "among 30% of [American] abortion patients covered by private insurance, nearly two thirds paid for abortion care out of pocket, which they attribute in part to stigma." This indicates that abortion stigma also contributes to increasing economic costs of abortion. Lastly, self-induced abortions continue to be prevalent in the United States, which is a significant health risk. Individuals who work in abortion provision suffer high rates of burnout, since exposure to stigmatizing behaviours may be continual.

Perpetuation

The causes of abortion stigma and the factors that perpetuate abortion stigma are often closely related. Certain factors may cause abortion stigma, which in turn perpetuates the factors that cause it. Here we discuss a model of stigma and its perpetuation, as well as potential sociological root causes.

Model of stigma perpetuation

As Kumar states, stigma can only be created by over-simplifying complex situations and abortion is no different. Link and Phelan's (2001) conceptualisation of stigma is applied here, in order to show firstly how stigma may originate in the context of abortion, and secondly, to show how the last stage may "feed into" the first stage, thus perpetuating abortion stigma. Link and Phelan (2001) assert that there are four sequential stages to the formation of stigma:

1. Labeling of Differences: First, differences between individuals are clearly marked. Since abortion is what some may call an "invisible" trait, since a woman usually shows no outward signs of having obtained an abortion, secrecy is particularly paramount in attempting to stop abortion stigma. Nonetheless, if someone is "outed" as having had an abortion, the difference between the individual and someone else becomes even more marked than otherwise.
2. Linking Differences to Negative Stereotypes: Women who have had an abortion are often associated with traits such as promiscuity, selfishness, dirtiness or having homicidal tendencies. These traits will vary from culture to culture, and abortions for different reasons may be associated more with certain traits than others.
3. Separating "Us" from "Them": As negative stereotypes are linked to individuals who have had an abortion, separation occurs between those who have had an abortion, and those who haven't. There can even be a separation observed between different women who have had abortions for "good" and "bad" reasons. Some women create distance between themselves and other women having abortions, in order to "view their experience positively." For example: in the US, certain women who had an abortion may look down on others who use abortion as a method of birth control.
4. Discrimination and Status Loss: Stages 1-3 may contribute to overt discrimination that women who have had abortions face. This, in turn, highlights the differences between women who have had an abortion and women who haven't, and Stage 1 may occur again. As women turn to secrecy in order to hide their differences, abortion rates are misrepresented, and something as common as abortion can be seen as "rare and deviant."

Sociological causes

There are several speculated sociocultural causes of abortion stigma. Some of the prevalent ideas are violation of "feminine ideals", attribution of personhood to the fetus, legal restrictions, ideas that abortion is "unhealthy", and due to being used as a tool for anti-abortion activism.

The manifestation and causes of abortion stigma is deeply dependent on the culture in which it is examined. Abortion is not universally "wrong" or "right" for the same reasons across cultures - the existence of a culture in which abortion stigma is very weak or non-existent is possible. For instance, in Cameroon, approximately one in five women have had an abortion, as surveyed in 1997. Abortions are highly restricted in Cameroon, and many types are illegal. However, abortion stigma in Cameroon comes mainly from the health risks and public shame that would be experienced by women, as opposed to illegality of the procedure or religious ideals.

Filial piety and feminine ideals

According to Kumar et al., (2009), abortion violates two fundamental ideals of womanhood: motherhood and sexual purity. Abortion is evidence that a woman has had non-procreative sex and seeks to exercise her reproductive rights.

Thuy, a 19-year-old from Vietnam, explains the guilt and shame she felt about abortion as such:

Motherhood is something honourable [in Vietnam], something to be proud of. To Vietnamese people, having children is something very sacred. Do you understand what sacred means? It means something very large, especially in the life of a girl.

In Vietnam, abortion services are relatively accessible, but many young men and women experience stigma and therefore keep abortions secret.In particular, the Vietnamese cite several reasons for feeling guilt about having gone through with an abortion -- firstly, a sense of doing wrong to the fetus, secondly, an offense to parents and their family, and thirdly, a sense of defying their own fate. Lastly, the case study of Ly, 21, shows that concern about "so many people who want to have a child, and can't" and cites this as a reason for the guilt of abortion. It seems that motherhood is something that is "fated" to occur, and if a woman becomes pregnant, it is her responsibility to keep the child.

As pre-marital sex and casual sex is condemned in Vietnam, as abortion is, teenagers who are unintentionally pregnant are particularly condemned. Tan, a 32-year-old Vietnamese woman, mentions how people will say that "she had sex casually and then destroyed the results". Hence, many Vietnamese turn to rituals, such as burning incense or offering of fruit, in order to to cope with the intense guilt that comes with having an abortion.

Attribution of personhood to the fetus

Most recently, there have been technological changes that facilitate the personification of the fetus and blur the line between more and less developed fetuses. Specifically, fetal photography, ultrasound and advances in care for pre-term infants create the argument that a developing fetus is actually just as sentient as a human infant. Abortion is then seen as murder, and the fetus is treated very separately from the woman who carries it, disregarding her circumstances or reasons why she may not wish to carry the pregnancy to term.

According to Beynon-Jones (2015), there is a conflation of the "truth" of fetal personhood with the image of the ultrasound -- ultrasound technicians naturally avoid showing the image to pre-abortive women. In the UK, they are asked whether they would like to have a look at the pre-abortion ultrasound of the fetus. One participant in the study mentioned how the use of ultrasound to "acknowledge/remember" the fetus was difficult given that she was not expected to want to look at the ultrasound pre-abortion. This is because some technicians phrase the question in a way that implies the woman should not want to look at the ultrasound -- for example, "We don’t normally show the screens, but do you want to?" Some women choose not to look at the ultrasound, and so cement their decision that abortion is the correct choice.

Abortion as "unhealthy" or "harmful to women"

Another prevailing view that anti-abortionists take, according to Norris et al., (2011), is that abortion is at its essence harmful or unhealthy to the woman. Unfortunately, abortion is in fact unsafe when it is done outside of a clinic, inside an unregulated clinic, or when it is self-induced, and this does mar the reputation of the abortion. There have been unsubstantiated links made between abortion, various cancers, and psychological "post-abortion syndrome".

Legal restrictions

Many US states have legal restrictions, such as parental consent requirements, waiting periods and mandated ultrasound viewings, that make it very difficult for women to obtain abortions. According to the Center for Reproductive Rights, 26% of all people live in countries where abortion is generally prohibited. This reinforces the notion that abortions are morally wrong, as well as being "reflections of ideologies and norms" of the US. Severe legal restrictions are correlated with unsafe abortion. However, it's important to note that the legalization of abortion is not enough to stop abortion stigma entirely -- when it was legalized an enduring cultural stigma is revealed.

The "global gag rule" is the mandate that non-US organizations may not use US family planning funds for purposes to do with abortion: they cannot perform, counsel for, or refer for abortion services, regardless of the non-US organization's policies. The effect of this is that abortion services are isolated from other medical services, and advocacy for abortions is "gagged".

Intersection with HIV stigma

According to inroads, an organization for the reduction of stigma, abortion stigma is often found exacerbated when it is found in conjunction with other stigmas, such as abortion stigma among adolescents, and HIV stigma. Social stigma among adolescents that obtain abortions has already been discussed, and here we will focus on HIV stigma.

In many areas of the world where HIV prevalence is high and abortion is restricted, rates of unsafe abortions are high as well. In some countries, abortion is only legal in cases of rape or incest. Women with HIV who decide to get an abortion are not supported, because testing positive for HIV is not a reason for which one can legally obtain an abortion. Hence, women living with HIV may resort to unsafe abortions. Also, women living with HIV are considered to be in a "double bind" situation: motherhood in countries such as Vietnam is generally wanted and encouraged socially, but for women with HIV, it is discouraged. In South Africa, abortion is perceived as more taboo than HIV by some women. However, many HIV-positive individuals consider their HIV status to be an aspect of their identity. Women living with HIV might face abuse from abortion providers -- some reported being told that "they could have an abortion only if they agreed to be sterilized thereafter."

Fighting abortion stigma

Considering the immense consequences of keeping one's abortion secret, one of the crucial ways of disbanding abortion stigma is to speak openly about abortion. Another way is to be careful about the language that society uses in relation to "good" or "bad" abortions - it's important to realize that there are no correct or selfish reasons to get an abortion. Yet another method is to strengthen training initiatives: there is a growing movement to make abortion training more research-based and to integrate it with academic medicine. The Family Planning Fellowship provides advanced abortion training in 21 universities in the US.

Change of discourse

Norris et al. (2011) argues that the normalization of abortion is important to fighting stigma. Since secrecy perpetuates the notion that abortion is not commonplace or is deviant, telling one's abortion story and making it acceptable to talk about abortion would reduce stigma.What may help us further understand how to fight abortion stigma is "comparing abortion to other phenomena that have become less stigmatized over time, such as homosexuality."

Kumar asserts that discourse plays a crucial role in the perpetuation of stigma. In some parts of the world, abortion is described in terms of "delayed" or "missed" pregnancies, which does not ascribe responsibility to anyone. However, those who provide abortions may be referred to as "abortionists" or "murderers", which equates abortion to a crime. Similarly, discourse that conflates a fetus with a newborn baby attributes personhood to it.

Similarly, among women who have had abortions, being aware of the language used to describe different kinds of abortions is important. Certain types of abortions, such as abortions for reasons of birth control, may be classified as "bad" and separated from abortions for other reasons. Refraining from these divisions may help lessen stigma.