Abstract: Research conducted over the last few decades has revealed an association between induced abortion history and substance abuse. The experience of induced abortion may be associated with psychological discomfort in some women and substance use offers a convenient remedy for alleviating the negative emotions without the necessity of disclosing the source of the discomfort.
On the other hand, many characteristics related to the choice to abort are also systematically related to the likelihood of using substances (e.g., relationship difficulties, pre-existing emotional problems, a tendency to engage in risk-taking behavior, etc.) and the correlations observed in the literature may be due to the presence of uncontrolled third variables.
Therefore, the general purpose of this review is to critically evaluate the available evidence linking induced abortion and substance abuse with sensitivity to the contextual complexity of both variables.
Specific objectives include the following: 1) provision of an overview of substance use disorders in women, 2) review of evidence
for a causal model, highlighting methodological deficiencies in the published literature, 3) identification of process
mechanisms (direct and indirect) through which induced abortion may enhance risk for substance abuse, 4) provision of
recommendations for further research, and 5) consideration of practice implications of the available findings.
Substance abuse has increased over the past 3 decades,
becoming a particularly disturbing problem among American women in recent years [1,2]…more women are attending college, working full-time, often in fields previously dominated by men, caring for aging parents, and women have experienced more personal control over reproduction since legalization of induced abortion in 1973 [3-8].
These changes have obviously brought many expanded opportunities for womens achievement relative to diverse roles while broadening avenues for personal fulfillment…
Nevertheless, each change carries the potential to likewise complicate womens lives and introduce new sources of stress, which may have an association with the higher frequency of substance abuse evidenced over the past three decades.
The focus of this article is on the possible causal link between induced abortion and substance abuse. Slightly over 50% of American women facing an unintended pregnancy decide to abort  and approximately 43% of women in the USA have had at least one induced abortion prior to age 45 .
Many women report pronounced stress and conflict associated with undergoing the procedure [10,11] and several studies published in recent years have suggested an association between induced abortion history and substance use/abuse [12-18].
The underlying assumption motivating the research is that the experience of induced abortion is associated with negative psychological effects (depression, anxiety, guilt, etc.) in some women and substance use offers an easily accessible means for alleviating the discomfort.
SUBSTANCE ABUSE IN WOMEN
Substance use disorders are typically divided into two categories: substance dependence and substance abuse .
Research pertaining to gender differences in substance
use/abuse suggests that women are more inclined to initiate
substance use in response to traumatic life events.
Among the experiences found to trigger substance use are physical or
sexual abuse, the sudden onset of an illness, and family problems . Compared to male substance users, females more frequently report a childhood environment of substance abuse  and higher levels of dysfunction in their families of origin . For example, studies suggest that 25 to 75% of women who abuse drugs or alcohol experienced childhood sexual abuse [23-26].
Compared to men, women are also more inclined to be plagued by feelings of guilt and self-blame and to experience low self-esteem in conjunction with substance abuse and they have a higher incidence of
depression, anxiety, and posttraumatic stress disorder comorbidity
Further, women who abuse substances are more inclined than men who abuse substances to be involved in a relationship in which the partner is abusive . Gilbert and colleagues  found that 64.9% of
substance-abusing women reported partner perpetrated
physical abuse, sexual abuse, or indicated that their partner
had threatened their lives. This rate of abuse is over twice as
high as national epidemiological surveys of the general
population of women .
Finally, compared to alcoholdependent men, alcohol-dependent women are less likely to seek treatment from a substance abuse treatment facility , are more prone to alcohol-related diseases
[33,34] and have a higher alcohol-related mortality rate .
Based on this brief overview of gender differences in substance abuse, it is clear that women who abuse substances are more likely to have suffered from multiple past and current challenging life situations and there is emerging evidence indicating that women use substances as a means of coping more frequently than men , perhaps because
women who are dependent on substances often have deficient social support networks … in the 1990s regular use of cocaine increased for women while men’s cocaine use declined slightly .
Based on an extensive review of the literature, Greenfield  concluded that the incidence of alcohol dependence among women in the U.S. has risen steadily since the early 1970s and is now comparable to that of men.
According to a report by the U.S. Surgeon General , the smoking rate among men declined from 51.9% to 37.5% during the period
extending from 1965 to 1979; whereas the decrease in the smoking rate of 33.9% to 29.9% among women within the same time frame was much smaller and the gender gap narrowed to a steady 5% by the mid 1980s. The decline in smoking rates among adult women tapered off in the 1990s and the smoking rate increased among the nations
adolescent female population during the 1990s.
Results from the 2003 National Survey on Drug Use and Health (SAMHSA, 2004) revealed that 57.3 % of males aged 12 or older were current drinkers compared with 43.2% of females; however, among individuals between the ages of 12 and 17, males and females had comparable rates of current alcohol use (17.1% of males and 18.3% of females). The results of the same study revealed that more males than
females aged 12 or older smoked cigarettes in 2003 (28.1%
vs. 23.0%); but for respondents between the ages of 12 and
17 comparable smoking rates were observed for boys and
girls (11.9% vs. 12.5% respectively).
The study further indicated that men were more inclined to report current illicit drug use than women (10.0% vs. 6.5%), and among
respondents aged 12 to 17, the rate of current illicit drug use
was similar for boys (11.4%) and girls (11.1%). Finally, among individuals aged 12 or older, males (12.2%) were twice as likely as females (6.2%) to be classified with substance dependence or abuse.
The rate of substance dependence or abuse among females (8.7%) was once again not significantly different from the rate among males (9.1%) for respondents between the ages of 12 to 17.
Substance abuse is potentially detrimental to womens health at any point in their lives; however substance abuse during pregnancy is particularly troubling due to established links with poor pregnancy and birth outcomes [39,40] as well as detrimental effects on childrens subsequent development [41,42].
Among pregnant women in the United States, 15-19% use alcohol [43,44], 14-20% smoke cigarettes [44,45], and 5% use one or more illegal drugs .
E FOR ASSOCIATIONS BETWEEN INDUCED ABORTION AND SUBSTANC
Accumulating research evidence indicates that a history
of induced abortion is associated with enhanced risk for
substance abuse post-dating the procedure. In a study of over
700 women in New York State, Yamaguchi and Kandel 
found that the use of illicit drugs other than marijuana was
6.1 times higher among women with a history of induced
abortion when compared to women without a history.
Similarly, research by Reardon and Ney  revealed that
among women with no prior history of substance abuse,
those who aborted when compared to those who continued
their pregnancies to term were 4.5 times more likely to
report subsequent substance abuse.
Eighty-nine percent of the women reported the onset of substance use to be within 3 years of the induced abortion. Similarly, research
conducted by Morrissey and Schuckit  at a Seattle
detoxification center revealed that problem drinkers and
alcoholics were more likely to report having experienced
alcohol related problems after as opposed to before an
Amaro and colleagues  found that adolescent drug users when compared to nonusers were significantly more likely to report a history of induced abortion (33% vs. 16.3%).
In the same study, no associations were identified between drug use and parity or other forms of perinatal loss (spontaneous abortion /stillbirth). Additional studies have identified significant associations between induced abortion and substance use/abuse [14,15, 48, 49].
Unfortunately, only one study conducted to date has used
an appropriate control group and compared substance use
rates among women who abort and women who deliver an
unintended pregnancy. Using data from the National
Longitudinal Survey of Youth, Reardon and colleagues 
recently reported that women who aborted, when compared
to those who carried to term, were twice as likely to use
marijuana and reported more frequent use of alcohol after
controlling for age, race, marital status, income, education,
and prior psychological well-being.
Negative induced abortion-related emotions, which may
enhance risk for substance use, could be triggered or
exacerbated by the physical and psychological changes
associated with a later pregnancy . For example, in a
recent study of pregnant women with a prior history of
induced abortion, 37% reported unresolved feelings related
to the induced abortion  and Bradley  found that
women, who had aborted, when compared to women without
a history of induced abortion, were more likely to report
anxiety during pregnancy. With regard to substance use,
studies comparing women with and without a history of
induced abortion have identified significant correlations
between a prior history of induced abortion and smoking
during pregnancy [52,53,54]. Further, a few studies have
demonstrated significantly higher rates of alcohol use
[55,56] and illicit drugs such as cocaine, methamphetamines,
and opiates [57,58,59] among pregnant women who have
aborted compared to pregnant women who have not.
Using data from a nationally representative sample, Coleman et al.
 found that pregnant women with a prior history of induced abortion were significantly more likely to use marijuana (odds ratio: 10.29), various illicit drugs (odds ratio: 5.60), and alcohol (odds ratio: 2.22) than women with a history of a prior birth.
Finally, in soon to be published study by Coleman, Reardon, and Cougle  a history of induced abortion was found to be associated with a higher likelihood of using substances of various forms (cigarettes,
cocaine, marijuana, and other forms of illicit drugs) in a subsequent pregnancy after statistically controlling for various demographic variables (odds ratios ranged from 2.0 to 5.06).
Interestingly, these researchers found no differences in substance use among women with a history of stillbirth or spontaneous abortion compared to women without the respective form of loss.
Although strong correlational evidence has accumulated
establishing a link between induced abortion and substance
use, a number of methodological improvements in the
research are necessary to determine if the association is
ANXIETY AS A MEDIATOR OF RELATIONS BETWEEN INDUCED ABORTION AND SUBSTANCE ABUSE
Substances are frequently used in an attempt to alleviate
stress ; therefore women who suffer from post-abortion
anxiety may be inclined to use or abuse alcohol or drugs in
an effort to self-medicate. Substance use may in turn
exacerbate mental health problems, leading to further
deterioration in psychological functioning…
In a recent review of literature, Bradshaw and Slade 
considered womens typical levels of psychological distress
immediately before an induced abortion and they noted that
the strongest studies indicate that 40 to 45% of women
experience high levels of anxiety. Feelings of relief and
reduced stress are commonly reported after the procedure
[63,64,65]; however, a minority of women (approximately
10-20%) suffer from serious post-abortion psychological
problems [66 70], which frequently include pronounced
When measured 2-4 weeks post-abortion, rates of anxiety
have typically been found to range from just under 8% to
In a recent review of the literature, Bradshaw and
Slade  concluded that up to 30% of women experienced
clinical levels of anxiety and/or high levels of general stress
one month after induced abortion.
Although not widely studied, a few investigators have explored possible links between induced abortion and more extreme stress reactions
indicative of posttraumatic stress disorder (PTSD).
Individuals with PTSD experience symptoms of avoidance
(efforts to escape from reminders of the event), intrusion
(e.g., unwanted thoughts, nightmares, flashbacks related to
the event), and arousal (exaggerated startle reflex, sleep
disturbance, irritability) for a month or more following
exposure to a traumatic event .
According to Speckhard and Rue , induced abortion may act as a traumatic stressor when it is perceived as involving the death of a
human being or as a serious threat to ones physical health.
In a study of 80 women in the United States, Barnard
 used standardized PTSD instruments and found that 3-5
years post-abortion, 18% of the sample met the full
diagnostic criteria for PTSD and 46% displayed high stress
reactions to their induced abortions.
Similar findings were reported by Hanley et al.  with the results indicating that some women report negative induced abortion-related
responses similar to the classic PTSD symptoms of intrusion,
avoidance, and arousal with these symptoms present many
years after the induced abortion.
Posttraumatic reexperiencing has also been documented in anniversary reactions.
For example, in a small study conducted by Franco et al. , 30 out of 83 women reported experiencing anniversary reactions, which included intense emotional psychosomatic pain. Major and colleagues  assessed PTSD symptoms using a scale adapted for specific reference to an induced abortion and determined that induced abortion
related PTSD was positively identified in 6 of 443 women
who had induced abortions two years earlier. However, only
38% of the women approached at the clinics participated in
the two-year follow-up.
In a study by Rue, Coleman, Rue, and Reardon , 65% of
American women and 13.1% of Russian women experienced multiple symptoms of intrusion, avoidance, and arousal associated with PTSD and 14.3% of
the American and 0.9% of Ru
ssian women met the full
diagnostic criteria for PTSD.
Finally, Congleton and Calhoun  compared two
groups of 25 women who elected induced abortion: those
who identified themselves as distressed and those who
reported more neutral or non-distressed responses…Women in the distressed group also were over twice as likely to report symptoms of
induced abortion trauma compared to women in the nondistressed
group. In this same study, women who identified
themselves as distressed post-abortion indicated feeling a
sense of loss/emptiness (48%), shock/detachment (28%),
anger toward partner/others (24%), depression (20%),
loneliness, betrayal, loss of self-worth, relief (16%), guilt
and sorrow (12%), confusion (8%), and fear of dying and
suicidal thoughts (4%). Interestingly, in the group of women
who elected induced abortion and did not believe they were
distressed, 20% had symptoms of depression, a percentage
similar to that experienced by the distressed group.
The authors concluded that for some women, induced abortion is
a “critical event” which produces high levels of psychological distress.
…a soon to be published study by
Cougle, Reardon, and Coleman  employing data from
the 1995 National Survey of Family Growth and based on
the responses of over 2800 participants revealed that women
who aborted an unintended pregnancy, when compared to
women who carried an unintended pregnancy to term, were
34% more likely to report an episode corresponding to
Generalized Anxiety Disorder in the first several years
following an induced abortion.
This study is particularly noteworthy because women who reported a period of anxiety prior to their first pregnancy event and women who reported having their first period of anxiety at the same age as their
first pregnancy event were excluded from the analyses.
Therefore, this study provides clearer evidence than
previously published work that induced abortion carries the
potential to trigger anxiety.
Association Between Anxiety and Substance Abuse
Stress has been strongly implicated in the etiology of
substance abuse and a number of studies have shown that
stress frequently leads to substance use relapse after a period
of abstinence [61, 83]. There is strong evidence for an
association between PTSD and substance use disorders [31,
84-87], particularly abuse of central nervous system
depressants . A general population study published in
1995 revealed a 7.6% lifetime rate of drug abuse or
dependence for women without a history of PTSD and
26.9% lifetime rate of drug abuse or dependence among
women with a history of PTSD.
Recent research has indicated that the onset of PTSD typically precedes the onset of substance use disorders, suggesting a causal relation [85,87]. In a study of over 1000 young adults, Chilcoat and
Breslau  found that PTSD was associated with a more
than 4-fold increased risk of drug abuse and dependence 3 to
5 years after an initial assessment. The authors suggested
that drug abuse or dependence in persons with PTSD might
be a result of their efforts to self-medicate.
A study by Lloyd and Laurence  revealed that 77%
of women (37 out of 48) who terminated a pregnancy in
response to knowledge of fetal malformation, experienced
acute grief after the induced abortion. Most women who
experience an involuntary perinatal loss such as a
spontaneous abortion or stillbirth will experience a grief
reaction with approximately 25% of women likely to suffer
from persistent, severe negative psychological consequences
. Because induced abortion is voluntary, associations
between induced abortion and feelings of loss, grief, or
bereavement have been less actively studied …
As noted previously, studies suggest that many women
develop emotional bonds to the fetus during pregnancy [113-
115] with one study by Leifer  indicating that maternal
attachment to the fetus may begin soon after conception.
Studies of early attachment have typically dealt with
pregnancies that were continued as opposed to having been
terminated and it may seem counterintuitive to suggest that
women who are planning to abort will develop similar
emotional connections to a developing fetus. However, there
is some preliminary evidence suggesting that the processes
underlying these early connections may be beyond the
conscious control of the mother. For example, Kemp and
Page  found that women with high-risk pregnancies
(due to the possibility of serious health complications or
even loss of life for the fetus or the woman) reported similar
levels of attachment to those undergoing uncomplicated
pregnancies. Coleman and Nelson  found that 30% of
college students who had experienced a past induced
abortion agreed or strongly agreed with the following
statement: I sometimes experience a sense of longing for
the aborted fetus, providing evidence of some connection
developed prior to the induced abortion.
Finally, Kero and colleagues  recently found that approximately 20% of women who experienced an induced abortion described
severe emotional distress in conjunction with the experience
with some of the women reporting having mourned the loss
of the child.
If women do develop an emotional connection to the fetus, then it is reasonable to hypothesize that they will be at a heightened risk for substance use as an effort is made to alleviate feelings of loss.
A feeling of loss under such
circumstances may be particularly difficult and confusing for
women residing in a society that generally views induced
abortion as a benign medical procedure as opposed to an
event involving termination of a developing human life,
because their pain is not socially recognized. Guilt feelings
may further complicate and hinder the mourning process
Induced abortion is voluntary, therefore many women
may experience a considerable amount of guilt or selfreproach
associated with the decision if their moral or
religious beliefs conflict with the decision [65,80,118]. The
percentage of women reporting guilt associated with an
induced abortion has been found to be rather high, ranging
from 29.7% to over 75% [65,80,118]…In Conklin and
OConnors  study of 800 women who had an induced
abortion, those who reported believing in the humanity of the
fetus experienced significantly more post-abortion negative
affect and decision dissatisfaction than women who did not.. in a
recent study conducted by Rue et al., 50.7% of American
women and 50.5% of Russian women who had an induced
abortion felt induced abortion was morally wrong .
In an interview-based study conducted by Patterson, Hill,
and Maloy , the results indicated that womens reasons
for choosing induced abortion were overwhelmingly tied to
their particular life circumstances (e.g., possible impact on
ones relationship with the father) as opposed to abstract,
moral or religious principles. Any conflict between the
induced abortion and personal and/or religious beliefs is
therefore likely to be suppressed in order to facilitate induced
abortion decision-making…For example, Foster and Sprinthall 
reported that the level of reasoning exhibited by young
womens abortion decision-making was significantly lower
than their general reasoning abilities. When reasoning
abilities that are temporarily suspended during the decision
are restored following the induced abortion, guilt reactions
Post-Abortion Anger, Resentment
Although anger in response to induced abortion has not
received very much scholarly attention, one small-scale
clinical study of 30 women who were partic
by an induced abortion experience revealed that 92%
reported feelings of anger, rage, and/or hostility that were
directed both inward and toward others . A few other
studies have identified anger as one of various negative postabortion
emotions examined [63,81]… Another potential source of anger
is when women feel they did not receive adequate
counseling/information from health care professionals….
Post-Abortion Relationship Difficulties
Unintended pregnancy can cause considerable strain on
relationships as each partners immediate and long-term
goals, values, and commitment to the relationship require
assessment in order arrive at a decision regarding resolution
of the pregnancy . A few studies have found that
induced abortion is related to an increased likelihood of
sexual dysfunction [80,134,135], communication problems
, and other relationship difficulties including separation
or divorce [80,100,136-138]. Other studies have, however,
suggested few changes in sexual or general relationships
with a partner following an induced abortion 
…Although very little research attention has focused on induced abortion as a risk factor for domestic violence, a few studies have
revealed an association between a history of induced
abortion and increased risk for violence during a subsequent
Many studies indicate that partner relationship problems are among the most common motives for seeking an induced abortion [141,142], with the experiences of partner sexual assault frequently found to be
associated with the choice to abort [143-145].
As noted in the introduction to this article, relationship problems are a
common source of substance use problems in women and
future efforts to understand how induced abortion may lead
to substance use should include careful attention to
relationship quality mediational processes.
…women who abort often describe themselves as
self-reliant, independent, rebellious, and enjoy being
unattached or unconnected to other people, places, and
things [51,106]. Personally believing that induced abortion is
acceptable, believing that family members support induced
abortion, and having a female relative with a history of
induced abortion are also predictive of the choice to abort
In a large-scale study by Zavodny , the following variables were correlated with higher rates of induced abortion compared to birth: discrepancy in age between the woman and her partner (an older male), race (Blacks were most likely to opt for induced abortion,
followed by Whites, and then Hispanics), and higher
educational attainment of the partner and of the womans
Finally, the choice to abort in adolescence has been
correlated with high academic achievement and high
educational aspirations as well as with being less religious
[148,149]…The choice to abort is often initiated by partners and
men frequently play a primary role in womens final
decisions [150-152]. Moreover, as noted earlier, the desire to
avoid single parenthood and partner relationship difficulties
including abuse are commonly reported reasons for induced
abortion [107,142,143,153,154]. Fear that a child will
interfere with the continuation of ones current intimate
relationship, future education, career, or personal plans
[121,155,156], young age , inadequate finances
[156,157], and lacking the time and energy for another child
 are other frequently reported reasons for choosing
OVERVIEW OF RECENT STUDIES INCORPORATING
In a recently conducted longitudinal study using data
from the Fragile Families and Child Well-being Study,
associations between induced abortion and substance use
among mothers of at least one young child were conducted
with controls for numerous potentially confounding variables
…Women were more inclined to choose to abort when paternal
involvement was rated poorly. The other three variables
found to predict the choice to abort included being
unmarried to the childs father when the child was born,
having considered an induced abortion for the earlier
pregnancy, and an assessment of the relationship with the
childs father as having remained the same or as having
become worse after the previous pregnancy was discovered.
Interestingly, substance use of various forms was not found
to predict the choice to abort; however, when the 14
covariates were used in the analyses, women with a history
of induced abortion when compared to women with a second
birth, were over three times more likely to report recent
heavy use of alcohol (consumption of 5 or more drinks on
one day in the past 30 days) and they were nearly twice as
likely to report recent cigarette smoking (in the past 30
A second study involved analysis of two waves of data
from the Survey of Adolescent Health (ADD Health) with
two primary phases . The results indicated that more that six
adolescents with induced abortion experience reported
frequent marijuana use for every one adolescent with birth
experience. Without the controls, induced abortion was
associated with a significantly higher risk for marijuana,
tobacco, and alcohol use compared to birth.
For various societal reasons induced abortion does not
represent a typical stressor that can be easily dealt with in
one of the most common ways people cope with stressful life
events, through reaching out to others for sympathy and
Because feelings of shame and secrecy frequently
cloak an induced abortion experience due to strong opinions
regarding the morality and legality of the procedure
expressed by a significant proportion of our society, women
may not feel comfortable confiding in others for needed
Studies clearly suggest that the presence of a sympathetic social support system is a vital component to effective recovery for the bereaved and as indicated above, many women do identify induced abortion as a death experience [161-163].
Cohen and Roth  found that
when women discussed an induced abortion decision with
others they experienced decreases in anxiety from before to
after the induced abortion when compared to women who
did not reach out to others for help.
Alcohol and drugs, which are readily accessible in our society, may be
used as a means for effectively suppressing or blunting
painful memories. Given the strong evidence suggesting
induced abortion may be linked to mental health problems
(described above) in a minority of women, professionals
should be actively encouraged to help avert negative
responses and encourage healing in those who are suffering.
Specific suggestions along these lines are described below.
There are many obvious problems associated with use of
substances as a means for coping with a painful induced
abortion. First, it is likely to facilitate avoidance and hinder
women from coming to terms with the underlying cause of
their discomfort. Further, as the emotional pain of an
induced abortion is denied, the many physical,
psychological, social, and practical problems associated with
substance abuse will in all likelihood introduce new sources
of suffering that in turn may fuel the trauma of an induced
abortion. Much of this cycle can be averted if women are
encouraged to explore ambivalent feelings before an
abortion and to make choices that are consonant with their
fundamental desires and values. In situations wherein
women are inclined to choose an induced abortion for
practical reasons or out of fears associat
ed with continuing
the pregnancy (e.g., disapproval from others, partner breakup)
despite an underlying desire to continue the pregnancy
and or conflicts with core values, counselors should
encourage them to explore how realistic their fears are and
assist in identifying sources of support within and outside the
family to make pregnancy continuation feasible.
Moreover, avenues for open expression of any negative emotions that
emerge during or after the procedure are critical. Induced
abortion providers need to understand and acknowledge the
complexity of womens emotional responses to induced
abortion, share literature regarding the wide range of
emotional responses, and encourage women to seek postabortion
help as needed.
Further, professionals who work with women who are suffering from anxiety or substance use disorders should sensitively inquire about the possibility of a past induced abortion in order to provide women with an
opportunity to express their feelings in a comfortable context
and foster more positive coping efforts as indicated. Efforts
directed toward treating women for substance use disorders
without addressing what in many instances may constitute a
primary cause are likely to be less effective and in some
cases may prove futile.
The complexity of individual, relationship,
situational, and societal variables that must be considered in
efforts to explain associations between induced abortion and
substance abuse is daunting as are methodological
requirements for sound research on the topic. Nevertheless,
given the destructive nature of substance use in the lives of
women, efforts to identify causes should be aggressively
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1573-4048/05 © 2005 Bentham Science Publishers Ltd.
Induced Abortion and Increased Risk of Substance Abuse: A Review of the Evidence
Priscilla K. Coleman
Human Development and Family Studies,
16D Family and Consumer Sciences Building,
Bowling Green State University, Bowling Green, OH 43403, USA
Received: October 13, 2004 Accepted: November 18, 2004