Overview

One of the most dramatic situations that an adolescent can experience is an unintended pregnancy and deciding what to do about it. These situations generally require counseling, both professional as well as informal, such as from trusted adults and peers. Yet, research that examines what adolescents do in these situations remains undeveloped, controversial, and marked by inconsistencies. The best research in the area focuses on basic statistics about the prevalence of pregnancies and abortions. Research on the outcomes of abortion has emerged, but much of it tends to not focus on adolescents. Commentaries relating to adolescents tend to focus on their rights, and little research has sought to understand how those rights are actually addressed in practice. Despite limitations in research, existing findings do reveal important findings that underscore the need for more research.

Prevalence of Abortions and Controversies

Unwanted pregnancies leading to abortions are common life events, and they relate directly to youth. Approximately 22% of the 205 million annual pregnancies end in abortion (Sedgh et al. 2007). In 2004 individuals less than 19 comprised approximately 17.4% of completed abortions, while 32.8% were ages 20–24 (Sedgh et al. 2007). Recent analyses (using data from 2011) reveal that, despite recent declines, teen pregnancy rates remain high in many countries, and the proportion of teen pregnancies that end in abortion varies widely across the countries (over 20) with complete estimates. For example, the adolescent abortion rate among those countries ranged from 17% in Slovakia to 69% in Sweden, and in half of the countries, 35%–55% of pregnancies ended in abortion (Sedgh et al. 2015).

Research also reveals an inverse relationship between pregnancy rates and the proportion of pregnancies ending in abortion. Countries with high teen pregnancy rates have a smaller proportion of those pregnancies end in abortion. This means that birth rates spread even greater in countries with high pregnancy rates. The example that is often given to understand this finding uses the rates from the USA and Switzerland. The US teen pregnancy rate is about seven times that of Switzerland, but the US birth rate is 15 times that of Switzerland (Sedgh et al. 2015).

Despite its prevalence, abortions raise a host of social and legal issues that challenge basic values and foster intense controversy. Indeed, researchers often charge that the scientific enterprise in this area of study is being manipulated and that research findings are being misrepresented to justify particular social agendas, especially efforts involving access to contraception and abortion (see Russo and Denious 2005). As expected, these controversies raise important concerns, not the least of which is the ability to get a firm grip on what research actually finds and what it means.

Controversies are likely to continue as they relate to mothers’ mental health outcomes relating to abortions and particularly as they relate to adolescents and their status. Research notes varied outcomes and mostly focus on adult women (see Major et al. 2009). Many reviews find similar conclusions, which is that, in the aggregate, women who terminate an unintended pregnancy are not at increased risk of mental health problems compared to women who carry an unintended pregnancy to term. But one meta-analysis found that abortion actually increases women’s risk of mental health problems, and it noted that it increases it by 81% and that 10% of mental health problems are attributable to abortions (Coleman 2011). That study has been subjected to many criticisms, such as the quality of the studies that it included (see Steinberg et al. 2012). Given the overall quality of studies in this area and the challenges facing efforts to provide more rigorous findings, it does appear that controversies will continue.

The existing controversies are important, but they also are limited. They tend to focus on elective abortions, and they also tend to ignore adolescents. This poses important challenges for understanding adolescents’ use and access to abortion counseling. Still, existing research does provide a springboard for uncovering important issues relating to other types of abortion (e.g., therapeutic and spontaneous abortions) and some of the important legal and clinical issues they might raise for adolescents.

Elective Abortions

Therapeutic and elective abortions typically are considered together, although they can be deemed considerably different. Therapeutic abortion is the deliberate termination of a pregnancy aimed at preserving the mental or physical health of the mother, preventing the birth of a lethally defective fetus, or reducing the number of fetuses in multiple conceptions to reduce health risks. Thus, an elective abortion is one done for any other reason. Over 90% of abortions occur during the first trimester, either utilizing surgical or nonsurgical procedures. Vacuum aspiration may be used during weeks 6–12, and medicinal abortion between weeks 0–9. Surgical options available after the first trimester are dilation and curettage used during 12–15 weeks, and dilation and evacuation is used 15–12 weeks. Dilation and extraction, performed after 21 weeks, are largely illegal in the USA since the passing of the Partial-Birth Abortion Ban of 2003, which the Supreme Court upheld in Gonzales v. Carhart (2007). The legal foundation of that case is important to consider given that it directly concerns many of the legal and policy issues relating to elective and therapeutic abortions, and those issues directly relate to counseling contexts.

In Carhart, the Court held that the partial-birth abortion ban did not impose an undue burden on the due process right of women to obtain an abortion. The Court did so by noting that the burden was not impermissible as framed under precedents assumed to be controlling, such as the Court’s prior decisions in Roe v. Wade (1973) and Planned Parenthood of Southeastern Pennsylvania v. Casey (1992). Roe v. Wade had recognized that a right to privacy under the due process clause in the Fourteenth Amendment to the US Constitution extends to a woman’s decision to have an abortion, but it had noted that the right needed to be balanced against the government’s legitimate interests for regulating abortions (protecting prenatal life and protecting the mother’s health). Finding that the state’s interests grew over the course of the pregnancy, the Court ruled in favor of permitting greater state regulation depending on the trimester of the pregnancy. That approach would be modified later to permit a right to abortion up to the point of viability, which is usually placed at 7 months (28 weeks) but may occur earlier. The Court adopted the viability approach in Planned Parenthood of Southeastern Pennsylvania v. Casey (1992).

In Planned Parenthood of Southeastern Pennsylvania v. Casey (1992), a deeply divided Court rendered a plurality opinion that recognized viability as the point at which the state interest in the life of the fetus outweighs the rights of the woman and abortion may be banned entirely except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother. The plurality opinion in Casey also crafted the rule that a restriction would be impermissible if it posed an undue burden on women’s rights to seek an abortion, with the undue burden defined as a restriction that had the purpose or effect of placing a substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus. Specifically in this case, the Court used the standard to find impermissible the need for spousal notifications but upheld the use of 24-h waiting periods, informed consent, and parental consent requirements on the grounds that they did not pose undue burdens. The focus on informed consent was to ensure that women had fuller knowledge of what abortions were, and parental consent requirements were efforts to ensure (with some exceptions) that parents were involved in the minor’s decision-making. These provisions highlight the tension between a focus on individual rights and a focus on seeking to ensure that individuals make deliberate decisions.

The tension between individual rights and those of others who might have a stake in the abortion decision is worth highlighting in that it is particularly important for adolescents. As noted, the Court in Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) had considered, among other provisions, the parental consent measure of an abortion statute. The statute provided that, except in a medical emergency, the informed consent of at least one parent (or guardian) was required before an unemancipated minor could obtain an abortion. The statute also provided a judicial bypass procedure, if neither parent gave consent, upon a finding that the young woman was sufficiently mature or that an abortion would be in her best interests. The Court ruled that a state may require a minor seeking an abortion to obtain the consent of a parent or guardian, provided that there is an adequate judicial bypass procedure. That approach confirmed what the Court had previously noted, in passing, in prior cases, most notably Bellotti v. Baird (1979).

It was in Bellotti that the Court had noted criteria that could make for a constitutional bypass provision. The provision must allow the minor to bypass the consent requirement if she establishes that she is mature enough and well enough informed to make the abortion decision independently, must allow the minor to bypass the consent requirement if she establishes that the abortion would be in her best interests, must ensure the minor’s anonymity, and must provide for expeditious bypass procedures. The Court strictly foreclosed parents’ absolute right to be consulted about, much less veto, their child’s decision to abort. This recognition has led the Court to require states to provide access to an alternative decision-maker, such as a judge, when the state imposes parental notice and consent conditions on the minor’s abortion decision. This balance serves as a compromise position between according minors the right to make their own decisions concerning the continuation of a pregnancy and according parents or guardians’ unchallenged authority to determine whether the pregnancy must be continued to term. But it does recognize that parents can serve important functions in that minors typically lack valuable attributes and resources (such as financial stability, education, and maturity) that an adult would be more likely to bring to a situation of unwanted motherhood. Clearly, whether parents are notified or give consent raises important tensions, and these same tensions emerge in counseling.

Important issues arise in counseling contexts, and they can vary throughout the decision-making process. In therapeutic abortion, individuals must first decide whether to continue with the pregnancy despite the risks. If indeed the pregnancy is wanted and possibly difficult to achieve, efforts are made to address potential feelings of uncertainty, grief, or despair. In these contexts, ethical and religious questions likely arise. In procedures involving elective abortion, pre-abortion counseling seeks to aid in the decision-making process and consideration of reasons and options. Counseling involves considering not only obstacles from their academic, career, and life plans but also responses from families or communities. Adolescent girls likely are in different positions than adults in that they also likely must consider their readiness for parenthood, stunted development, and family discord. In elective abortion contexts, postabortion counseling may not be necessary, as a range of emotions may be present including sadness, anxiety, guilt, and regret, but also positive emotions. Counseling most likely is needed in contexts where the adolescent lacks social support, feels coerced in the decision-making, has high ambivalence, or has other preexisting circumstances that can contribute to negative postabortion reactions. For postabortion counseling, no standards have been published; however, women generally are helped to identify emotions and life circumstances impacted by their decision. Psychoeducation may be given regarding new coping skills, and religious aspects may be considered to facilitate personal resolution. Importantly and depending on resolutions, counseling may be provided during the process itself, and it also may be needed later.

Spontaneous Abortions

Spontaneous abortions, or miscarriages, occur before 27 weeks of pregnancy and result in infant death. While 12–15% of clinically known pregnancies end in miscarriage, many more occur before anyone recognizes the pregnancy, thus increasing the miscarriage rate to an estimated 45–50% of all pregnancies. Risk appears to increase with age, with women ages 20–24 having a 9% chance. Sometimes miscarriages may be physically painful processes, with the negative experiences sometimes compounded by the very private nature of the event. Miscarriage puts individuals at risk for depressive symptoms, major depression, anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder (Klier et al. 2002; Geller et al. 2004). Some women may be concerned about immediate medical issues and underlying factors for the miscarriage. Here, post-loss counseling aims to validate death and normalize feelings of grief. Symptom reduction, grief management, utilization of coping resources, and psychosocial factors also may be addressed. Research in this area has not centered on the needs of adolescents, although adolescents’ status and developmental needs may raise distinct issues.

Mature Minors

One of the most important issues regarding counseling for minors involves, as noted above, the involvement of adults. In 38 states in the USA, pregnant minors can obtain an abortion without parental consent through a judicial bypass. To obtain that bypass, a court must determine that the minor is either sufficiently mature and well enough informed to intelligently decide whether to have an abortion or that notifying her parents is not in her best interests (such as due to the risk of abuse). Few studies have sought to describe the characteristics of minors who do seek these options and the outcome of the proceedings.

One important study was recently completed in Ohio (see Friedman et al. 2015). The study, which took 3 years to conduct, evaluated 55 cases. Their average age was 16 and the vast majority (95%) received permission to seek their abortions without parental consent. Importantly, the study also found that the minors who sought the judicial bypass had long-term boyfriends who were close in age to them. It also found that they had consulted trusted adults but did not want to approach their parents for fear of violence or of being shunned from their families. It is not clear what percentage of adolescents seeking an abortion request judicial bypasses, but it does seem clear that parents tend to be aware and play at least an informal role in counseling minors, especially teens below the age of 16.

Conclusion

Whether intentional or unintentional, abortion remains prevalent. It necessarily involves numerous complex and difficult issues. Those issues are likely even more complex when dealing with adolescents. In addition to dealing with psychological, moral, and social considerations, this area of adolescents’ experiences also involves complex laws that raise important issues and try to balance many rights and responsibilities. Despite those complexities and perhaps because of intense controversies, research relevant to adolescents has been sporadic and much of the research in this area, including writings that focus on clinical issues, tends not to focus on adolescents’ particular needs (see Coleman 2006; Levesque 2000). Despite the lack of research, there is no doubt that this remains an important part of normative adolescence that affects adolescents in many ways.

Cross-References