Final pre-print version of: Macleod, C. (2012). Feminist Health Psychology and abortion: towards a politics of transversal relations of commonality. In C. Horrocks and S. Johnson (Eds.), Advances in Health Psychology (pp. 153-168). Basingstoke: Palgrave Macmillan. FEMINIST HEALTH PSYCHOLOGY AND ABORTION: TOWARDS A POLITICS OF TRANSVERSAL RELATIONS OF COMMONALITY Catriona Macleod, Rhodes University, South Africa In 1992 Speckhard and Rue argued in the Journal of Social Issues for the recognition of a diagnostic category, post-abortion syndrome (PAS). This term was first used in 1981 by Vincent Rue in testimony to the American Congress, but was only formalised in a published paper a decade later. Speckhard and Rue (1992) posit that abortion is a psychosocial stressor that may cause mild distress through to severe trauma, creating the need for a continuum of categories, these being post-abortion distress, post-abortion syndrome and post-abortion psychosis. PAS, which is the main focus of their paper, and which has taken root in some professional language as well as lay anti-abortion discourse, is described as a type of posttraumatic stress disorder. These moments (the testimony to the American Congress by Vincent Rue, the formal academic paper by Speckhard and Rue (1992)) epitomise the psychologisation of abortion that took root in the 1980s. Portrayals of the woman undergoing an abortion shifted during this time from somebody selfishly denying the foetus its right to life, or alternatively exercising her right to control her body and fertility, to somebody who unwittingly subjected herself to psychological harm through terminating her pregnancy (Lee, 2003). As such, the woman, who previously had been circumscribed by moral, health or gender narratives, started to be described in psychological terms. Her body, self, emotions, and psyche were rendered visible within psychologised discourses (Rose, 1990), which mostly constructed her as the victim of inevitable depression and grief following a necessarily traumatic abortion event. This process of psychologisation started in the United States, but has been taken up in a range of forms in other parts of the world, including the United Kingdom (Hopkins, Reicher, & Saleem, 1996) and South Africa (Macleod, 2011). It has resulted in vigorous scientific debate regarding the psychological consequences of abortion (see, for example, the exchange between Reardon and Cougle (2002) and Schmiege and Russo (2005) in the British Medical Journal and the letters that followed each article), and has become part of the overt politics of abortion with anti-abortion activists using PAS to ‘redefine the terms of the debate so that abortion is represented as contradicting women’s interests’ (Hopkins, Reicher & Saleem, 1996, p. 545). The psychologisation of abortion has, however, mostly occurred within the context of relatively liberal abortion laws where abortions are performed relatively safely. While women in countries such as the United Kingdom and the United States have, for the most part, had access to safe legal abortion for decades, it is estimated that in 2003 about 20 million unsafe abortions took place, 98 per cent of which were performed in developing countries (World Health Organisation, 2007). Debate about the psychological consequences of, and hence a psychological discourse concerning, abortion is virtually non-existent in these contexts, chiefly because the most devastating effects of unsafe abortion are death or severe reproductive health outcomes (Warriner & Shah, 2006). Other than the obvious differences concerning more or less restrictive abortion laws, how abortion is viewed differs significantly from country to country. It is an issue that speaks to, and draws on, localised understandings of the role of women, the role of the state, the sanctity of life, society’s obligation to women and the right to privacy. The practice of abortion also differs vastly. For example, compare the situation in post-Soviet countries and Cuba with the situation in South Africa. In the former, the term ‘abortion culture’ has been coined to refer to ‘the widespread and deep-seated view that abortion is a “normal” way of dealing with medical and socioeconomic hardships in personal and family life’ (Karpov & Kaumläriäinen, 2005, p. 13). In the latter, abortion, despite being legal since 1996, continues to attract significant social stigma as a result of traditional moral values, so that fear of rejection by the community and partners limits women’s use of the service (Department of Health, 2004). In this chapter I pose the question of how feminist health psychologists should respond in light of (1) the psychologisation of abortion in particular contexts, (2) the uneven response of Psychology in relation to abortion globally, and (3) the fact that abortion differs significantly both in legislation and as a social and cultural practice from country to country. I focus here on feminist health psychology as abortion has for some time now been a key feminist issue. Despite this, little has been written specifically about how health psychology may further the feminist agenda in terms of this aspect reproductive health. In this chapter I argue, in the first instance, that the psychologisation of abortion in certain contexts dovetails, paradoxically, with the emphasis on ‘choice’ that underpins the mainstream Western feminist lobby for abortion. In order to avoid the pitfalls implicit in both the ‘choice’ rhetoric and PAS, feminist health psychology would be well served to turn to a framework of ‘reproductive justice’ rather than ‘choice’. In the second instance, I discuss how feminist health psychologists could extend this framework by joining the public health debate concerning abortion in developing countries where the most unsafe abortions occur. Finally, I argue for a feminist politics of transversal relations of commonality in terms of reproductive justice and freedom, in order to accommodate the possibly antagonistic approaches that feminist health psychologists may take in different settings regarding psychology and abortion. PAS and the rhetoric of ‘choice’: focussing on the individual woman and the abortion event In this section I argue that in order for feminist health psychologists to arrive at a position on abortion, we need to grapple with the fundamental principles that have driven both mainstream Western feminist advocacy regarding abortion and the proposal of PAS. As indicated below, some of the underlying assumptions of each are remarkably similar, despite the fact that the anticipated outcomes are quite different (with mainstream feminist advocacy envisaging increased access to abortion (Ferree, 2003) and PAS advocates indicating that abortion should be restricted in order to avoid wide-scale psychological fall (Hopkins, Reicher & Saleem, 1996)). I discuss below some of the chief tenets of mainstream feminist advocacy, criticisms thereof and its paradoxical linkages with PAS. ‘Choice’ and rights have been the cornerstone principles of mainstream Western feminist advocacy around the legalisation of and access to abortion. Fundamental to this advocacy is the argument that a woman should have the right to make decisions about her own body and that the choice concerning the outcome of a pregnancy should be the woman’s alone. This position draws off liberal political theory, with women’s competence to make abortion decisions being recognised and the state being forced to withdraw from any coercion in a significant area of women’s lives (Ferree, 2003). For example, the American Roe v. Wade decision ‘sent a clear material and rhetorical signal to women, girls, and the larger society: women’s reproductive lives should be, and henceforth would be, governed by a regime of choice … and not by fate, nature, accident, biology, or men’ (West, 2009, p. 1401). In this way, American women’s autonomy and life options were broadened, with liberal feminists arguing that in order to control their lives women had to be able to control their reproductivity. Without this, a woman would be denied equality with men: ‘Without selfsovereignty over her body, all that remains of her life—her work, her sociability, her education, her mothering, and her impact on the world—is miniaturized. She lives a smaller life’ (West, 2009, p.1401). Several critiques have been forthcoming concerning the notion of ‘choice’ as the mainstay of abortion advocacy. These have centred on: (1) the assumption of active unfettered agency on the part of women seeking abortions which belies the power relations within which ‘choices’ are made (Petchesky, 1980); (2) a lack of examination of ‘the social context and conditions needed in order for someone to have and exercise rights’ (Fried, 2006, p. 240) and of the social conditions which put pressure on women to abort ‘incorrect’ (for example, female) foetuses (Saharso, 2003); (3) the suggestion that the appropriate response to unwanted, coerced or violent sex that may result in an unwanted pregnancy is to protect the decision to end the pregnancy rather than to address the gendered conditions that lead to unwanted sex (Smyth, 2002; West, 2009); (4) the logical conclusion that the ‘choice’ to parent is as much an individual decision as the ‘choice’ not to parent, which means that individuals have to take full responsibility for their children and which legitimates inadequate social health and welfare programmes (West, 2009); (5) the failure to ‘address the existing social relations and sexual divisions around which responsibility for pregnancy and children are assigned’ (Petchesky, 1980, p. 670); (6) the masking of the fact that the fight for legal abortion has been associated in some quarters with eugenicist population policies which saw women’s right to have children curtailed through, for example, being unknowingly sterilised or being injected with long-acting hormonal contraceptives without full informed consent (Fried, 2006). What these critiques have in common is that they locate the woman within the context of her social, economic and health support milieu and her interpersonal and reproductive history. As indicated by Ferree (2003) in her study of feminist advocacy for abortion, mainstream Western feminist advocates agree that the notion of ‘choice’ may be limited, but argue that it should remain the core of activism around abortion. The limitations of the ‘choice’ rhetoric to which they point are the fact that it hides the stigma associated with abortion and that women face several obstacles in terms of accessing abortion (Ferree, 2003). The latter critiques, however, focus on processes that are insufficiently supportive of women in choosing abortion rather than on processes that are insufficiently supportive of women in avoiding unwanted pregnancies or in having and providing for children. In other words, abortion is foregrounded, while the complexity of women’s sexual, reproductive and mothering lives recedes into the background. West (2009) argues that this had to do, in the United States, with the politics surrounding the Equal Rights Amendment movement: Abortion rights were [for the first two-thirds of the last century] a branch on a tree, the trunk of which was the aspiration of equal citizenship and whatever social reimagining of basic structures of work and governance would be necessary to achieve it … [A]dvocacy for abortion was in effect severed from its trunk largely because of the politics surrounding the Equal Rights Amendments (ERA) movement and then transplanted into the quite different terrain of individual liberty. It then became its own “tree,” rooted not so much in women’s equality, but in marital, medical, and sexual privacy (p. 1423). This unmooring of mainstream American abortion advocacy from its roots, the concentration on the individual and her choice rather than the social conditions under which women live, and the foregrounding of abortion as the key issue in reproductive freedom means that the fundamental terms of the debate used in ‘choice’ rhetoric are the same as those used in the proposal of PAS. As I have argued elsewhere (Macleod, 2009), the term ‘post-abortion syndrome’ is a reductionist concept that places emphasis on the abortion event itself and on the individual woman, in much the same way, ironically, as advocacy based on ‘choice’ does. In utilising a category termed post abortion syndrome psychologists ignore the fact that termination of pregnancy occurs in the context of, firstly a severely problematic and unwanted pregnancy, and secondly particular interpersonal, sociocultural and economic stressors. PAS places the abortion in the foreground, while neglecting the stress and possible trauma inherent in: the discovery of an unwanted and severely problematic pregnancy; the fears around economic hardship; the difficult process of deciding how to resolve an unwanted pregnancy, especially in the absence of support; the expectation (whether real or imagined) of criticism, stigma and social isolation, not only because of the abortion but also because of the pregnancy; the potential lack of support and caring amongst health service providers; the lack of support structures for both child and mother carrying a pregnancy to term; and general contextual, sociocultural and socioeconomic issues (such as in South Africa the scourge of HIV, which sees many women having to take on additional care-taking roles as relatives fall ill or die, leaving children who need to be taken care of). Of course, the assumptions made about the individual woman in ‘choice’ rhetoric and in PAS differ substantially. Within the ‘choice’ rhetoric, women are depicted as rational and autonomous beings, able to exercise agency in decision-making regarding the outcome of a pregnancy. Within the narrative of PAS women are positioned as victims in need of protection and care and as lacking sufficient rationality and autonomy to make an informed decision about terminating a pregnancy (Lee, 2003). Women, from this perspective, are duped into undergoing an abortion by overzealous pro-abortionists or by service providers who profit financially through performing abortions. This positioning has allowed for the development of an anti-choice woman-centred strategy that complements the focus on the foetus that has traditionally underpinned anti-abortion activism (Cannold, 2002). As Ferree (2003) notes: [G]endered antiabortion mobilization … takes up themes of women’s exploitation and victimization and uses them, paradoxically enough, against feminism. … They appeal to this constituency [marginalised women] by positing a “postabortion syndrome” of guilt and remorse, which can make sense of some women’s regrets over a decision that they felt was not a real choice in practice (p. 336). Psychologists (e.g. Major et al., 2008; Schmiege & Russo, 2005; Stotland, 2001) who argue against PAS have had to engage in significant labour to dislodge the underlying assumptions of the abortion as the key event and the individual woman as the focus of attention. This has been achieved mostly through concentrating on methodological issues, in particular that studies in which PAS is found often do not take a number of confounding variables such as prior psychological functioning, partner support, material conditions, and social and cultural background in account, and frequently do not have valid control or comparison groups. The American Psychological Association (APA) task force on mental health and abortion (TFMHA) reports: A critical evaluation of the published literature revealed that the majority of studies suffered from methodological problems, often severe in nature.… The TFMHA reviewed no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors. (Major et al., 2008, p.3-4, emphasis added). To conclude, choice rhetoric draws off liberal political theory to posit a women’s competence to make abortion decisions. PAS, on the other hand, highlights the individual woman’s psychological response to abortion. Despite having different aims, the major difficulty with both ‘choice’ rhetoric and PAS is that they foreground the abortion event and focus attention on the individual woman and her (in)capacity for agency. In the following section I explore the potential of a ‘reproductive justice’ approach. The advantages of a ‘reproductive justice’ approach A reproductive justice approach highlights the contextual nature of women’s lives. Given overarching socioeconomic inequalities, racism and sexism that shape many women’s lives, the reproductive justice approach focuses on achieving conditions that are necessary for comprehensive reproductive and sexual freedom (Fried, 2006). West (2009) explains that Reproductive justice requires a state that provides a network of support for the processes of reproduction: protection against rape and access to affordable and effective birth control, healthcare, including but not limited to abortion services, prenatal care, support in childbirth and postpartum, support for breastfeeding mothers, early childcare for infants and toddlers, income support for parents who stay home to care for young babies, and high quality public education for school age children (p. 1425). Such an approach incorporates, but does not centralise, a strong political case for legal abortion as being important to women’s equal citizenship (West, 2009). It also regards ‘reproductive freedom – indeed, the very nature of reproduction itself – [as] irreducibly social and individual at the same time; that is, it operates “at the core of social life” as well as within and upon women’s individual bodies’ (Petchesky, 1980, p. 663). For the feminist health psychologist adopting such an approach, the social and interpersonal conditions under which unwanted pregnancies occur, as well as the experience and outcomes of the unwanted pregnancy, shift to the foreground, with abortion decisions and women’s experiences of abortion forming part of this broad landscape of understanding. The rationale for this can be found in the fact, as reported by the TFMHA, that women’s psychological experience of abortion is not uniform, but rather varies as a function of characteristics and events that led up to the pregnancy: the circumstances of women’s lives and relationships at the time that a decision to terminate the pregnancy was made; the reasons for, type, and timing of the abortion; events and conditions that occur in women’s lives subsequent to an abortion; and the larger social-political context in which abortion takes place. Mental health and problem behaviors observed after abortion are often a byproduct of conditions and characteristics that preceded or coexist with the unintended pregnancy and abortion (Major et al, 2008, p. 10). Thus, for example, we can start to unravel the factors associated with unwanted pregnancies, such as poor reproductive health information and education, poor reproductive health services, women’s vulnerablity to sexual exploitation, rape (Chhabra, Palaparthy & Mishra, 2009) and intimate partner violence (Stephenson, Koenig, Acharya & Roy, 2008), poor socioeconomic status, short previous pregnancy intervals, and large current family size (Faghihzadeh et al., 2003), all of which are intricately linked with gendered relations in complex ways. We can begin to understand how ‘unwanted pregnancies can be experienced as violations not only of women’s bodies and autonomy but of their very identities’ (Mullin, 2005, p. 71; see also the work of Lundquist, 2008). We can also locate abortion within its sociocultural discursive context, acknowledging that, social and cultural messages that stigmatize women who have abortions and convey the expectation that women who have abortions will feel bad may themselves engender negative psychological experiences. In contrast, social and cultural messages that normalize the abortion experience and convey expectations of resilience may have the opposite effect (Major et al, 2008, p. 12). We can acknowledge that unwanted pregnancies are harmful not only because of women’s experiences, but also for those born from unwanted pregnancies. This is clearly seen in what are referred to as the Prague studies in which children born in 1961-1963 to women twice denied abortion for the same pregnancy and pair-matched controls (matched for age, socioeconomic status and the partner's presence in the home) were assessed intermittently over 35 years, in which it is concluded that being born from an unwanted pregnancy is a risk factor for poor mental health in adulthood (David, Dytrych, & Matejcek, 2003). A ‘reproductive justice’ approach which centralises advocacy for comprehensive reproductive and sexual freedom (with legal abortion being argued for within this framework) thus permits a broad platform for understanding and activism around sexual and reproductive health issues. Extending feminist health psychology’s voice, public health and unsafe abortion In this section I argue that the above-mentioned reproductive justice approach within feminist health psychology needs to be extended to include, perhaps contradictorily, a discussion of the psychological consequences of unsafe abortion. Feminist health psychologists need to join the public health debate on abortion in contexts where it is severely restricted. The public health costs of restrictive laws and poor access to abortion have been highlighted in recent advocacy efforts concerning abortion. It is estimated that the maternal mortality ratio (MMR) is 450 maternal deaths per 100, 000 live births in developing countries – compared to 9 per 100, 000 in developed countries – with unsafe abortion being one of the leading causes of maternal death (WHO, UNICEF, UNFPA, & The World Bank, 2007). Where legislation allows abortion for a range of reasons, there is a decrease in both mortality and the health complications that arise from unsafe abortion. In addition, there are fiscal benefits, since the ‘direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies’ (Grimes et al., 2006, p. 1908). The success of the public health approach to advocacy is evidenced in countries such as South Africa (Klugman & Varkey, 2001), Nepal (Shakya, Kishore, Bird, & Barak, 2004) and Nigeria (Oye-Adeniran, Long, & Adewole, 2004), all of which have seen a liberalisation of abortion laws. What is striking about the public health approach to abortion is the absence of comment by psychologists. For example, in a Guttmacher Institute publication, which brought together ‘internationally prominent researchers from a variety of disciplines to assess the global status of unsafe abortion and to identify a research and action agenda’ (Warriner & Shah, 2006, p. viii), there is a distinct lack of discussion of psychological issues. Where mental health does feature, it is mentioned in relation to legislation which allows abortion on the grounds of threat to the mental health of the woman. This lack of comment by health psychologists in general is of concern. The absence of comment by feminist health psychologists is particularly troubling in light of fact that evidence is available that links gender disadvantage, reproductive health and mental health issues (for example, Patel et al., 2006). It must be conceded, however, that research on the consequences of unsafe abortion has been dominated by concerns with physical health complications. In a text on mental health issues in women’s reproductive health, Astbury and Allanson (2009) note: The mental health consequences of unsafe abortion are not known, although qualitative data suggest that unsafe abortion can be traumatic before, during and after the abortion, and is likely to cause psychological harm. … It is important to bear in mind that the lack of evidence and research on the mental health effects of conditions that predominantly affect women in low-income countries does not imply that there are no mental health consequences of these conditions … The stress of facing an unintended pregnancy or unsafe abortion might be expected to increase the risk of onset, or recurrence, of serious mental ill-health (pp. 54-55). Although there is some evidence accruing concerning the psychological consequences of unsafe abortion (for example, Herrera & Zivy, 2002), clearly more needs to be done in terms of complementing evidence concerning the physical outcomes of unsafe abortion with evidence on the possible psychological and social fall-out. What is important in this kind of research is to note the methodological issues outlined in relation to studying the experiences of women under conditions where abortion is legal. Specifically, locating the abortion experience within the context of an unwanted pregnancy, which occurs within particular economic, social, cultural, familial, health and gender relations circumstances, needs careful attention. A feminist politics of transversal relations of commonality Given the uneven response of Psychology to abortion as well as the legislative, social and cultural specificity of abortion, the question of whether feminist health psychologists can come to any agreement regarding their positions on Psychology and abortion is pertinent. I argue, in this section, that a politics of transversal relations of commonality is indeed possible. Such an approach, which I have outlined in detail elsewhere (Macleod, 2006), has a number of features. Of importance here is that it, firstly, attunes its pronouncements on liberatory practices and discourses to social and historical conditions and, secondly, deploys multiple sources of resistance along chains of equivalence or transversal relations of commonality. In the first of these requirements, determining the liberatory status of any discourse is not a matter of theoretical or political pronouncement. Rather, these determinations are a matter of social and historical inquiry. Thus, in relation to the discussion above a discourse of ‘women as victims of abortion’ potentially has on the one hand liberatory effects in situations where abortion laws are restrictive and unsafe abortion is rife. Emphasising the medical and psychological consequences of unsafe abortion is essential in terms of feminist advocacy for women’s reproductive justice and freedom in these contexts. On the other hand, a discourse of ‘women as victims of abortion’ in the context of legal and safe abortion has, as noted above, the reverse effect. Emphasising the contested (and mostly limited) medical and psychological consequences of legal and safe abortion in isolation from the various factors referred to earlier has the effect of restricting women’s access to reproductive justice and freedom. It must be noted here, however, that the strategic use of a discourse of ‘women as victims of abortion’ is not simply opportunistic. Instead it is based on sound empirical evidence, as noted earlier in this chapter, that the medical and psychological consequences of abortion differ significantly under various conditions. Within the approach I am advocating, the racial, geographical, economic, and class-based differences between women, all of which have central implications in terms of their access to health resources and their experiences of reproductive justice, are recognised. This means, thus, that the grounds for feminist action for reproductive justice around abortion and psychology are adjusted to suit the specific historical, geographical and cultural location. There is a refusal of foreclosed identities (i.e. seeing women as a single oppressed class across time and space), and a moulding of advocacy efforts to the nuances of gendered power relations within a particular context. Hand-in-hand with a cultural, social and historical specific approach and the refusal of foreclosed identities, however, goes a pursuit of transversal relations of commonality. Thus, although feminist health psychologists may use the language of psychological harm in the context of unsafe abortion and point to the dangers of this language in the context of safe, legal abortion, what underpins their pronouncements is a recognition of (1) the centrality of reproduction in women’s lives, (2) the imperative of promoting reproductive health and access to healthcare, (3) the intersection of mental and reproductive health, and (4) the pivotal role of gendered power relations in moulding women’s lives. It is the recognition of these elements that provides the chain of equivalence, or the transversal relations of commonality, around which health psychology feminists can agree. Feminist health psychology practice, thus, becomes a matter of alliances around central chains of equivalence rather than one of unity around a universally shared interest (such as promoting ‘choice’). Within this politics of difference, the aim is to establish multiple points of resistance to ensure reproductive justice that is attuned to the myriad relations of inequality and domination that occur in women’s reproductive lives. Acknowledgements Thank you to: Tracy Morison who assisted with a literature search and editorial corrections; Tracy Morison, Clifford van Ommen and the editors of this book who commented on a draft of this chapter; and Rhodes University and the National Research Foundation of South Africa for funding my research on abortion. References Astbury, J. and Allanson, S. 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