The Stigma of Having an Abortion: Development of a Scale and Characteristics of Women Experiencing Abortion Stigma
CONTEXT: Although abortion is common in the United States, women who have abortions report signifi cant social By Kate Cockrill, stigma. Currently, there is no standard measure for individual-level abortion stigma, and little is known about the Ushma D. social and demographic characteristics associated with it. Upadhyay, Janet Turan and Diana METHODS: To create a measure of abortion stigma, an initial item pool was generated using abortion story content Greene Foster analysis and refi ned using cognitive interviews. In 2011, the fi nal item pool was used to assess individual-level abor- tion stigma among 627 women at 13 U.S. Planned Parenthood health centers who reported a previous abortion. Factor analysis was conducted on the survey responses to reduce the number of items and to establish scale validity Kate Cockrill is research analyst, and reliability. Diff erences in level of reported abortion stigma were examined with multivariable linear regression. Ushma D. Upadhyay is assistant research RESULTS: Factor analysis revealed a four-factor model for individual-level abortion stigma: worries about judg- scientist, and Diana ment, isolation, self-judgment and community condemnation (Cronbach’s alphas, 0.8–0.9). Catholic and Protestant Greene Foster is women experienced higher levels of stigma than nonreligious women (coeffi cients, 0.23 and 0.18, respectively). On associate professor, all at Advancing the subscales, women with the strongest religious beliefs had higher levels of self-judgment and greater perception New Standards in of community condemnation than only somewhat religious women. Additional diff erences were found by race, age, Reproductive Health, education, religiosity and motherhood status on the subscales. Bixby Center for Global Reproductive CONCLUSION: This valid and reliable scale can be used in research examining abortion stigma and related Health, University outcomes (e.g., women’s health, relationships and behavior). The scale can also be used to evaluate programs and of California, San Francisco. Janet interventions that aim to reduce the stigma experienced by women who have abortions. Turan is associate Perspectives on Sexual and Reproductive Health, 2013, 45(2):79–88, doi: 10.1363/4507913 professor, Depart- ment of Health Care Organization and Each year, 1.2 million women in the United States have toward abortion and about women’s roles and responsi- Policy, School of Public Health, Uni- abortions.1 Half of unintended pregnancies end in abor- bilities lead to stigma for women who have abortions. versity of Alabama at tion, and nearly one-third of women have an abortion Goffman describes three types of stigma: blemishes of Birmingham. during their reproductive years.1,2 Women who choose character, deformations of the body, and tribal or group abortion commonly report the desire to be a responsible identity.9 Norris et al. point out that abortion stigma can parent to current or future children as paramount in their have many targets: women who have abortions, abortion decision.3 Although women routinely choose abortion in providers and even abortion rights advocates.10 The expe- response to diffi cult circumstances, many encounter social rience of stigma varies signifi cantly among these groups. stigma as a result of their decision. For women, abortion might be experienced as a blemish Substantial proportions of the U.S. public have nega- on individual character or even as a social demotion into tive attitudes about the morality and legality of abortion.4 the category of “bad girls and fallen women.”11(p. 3) Kumar, More than half of Americans aged 18 and older believe that Hessini and Mitchell describe abortion stigma as “a nega- having an abortion is morally wrong.4,5 In addition, large tive attribute ascribed to women who seek to terminate proportions of Americans do not think abortion should a pregnancy that marks them, internally or externally, as be legal and available for women who “cannot afford any inferior to ideals of womanhood.”7(p. 628) We propose that more children” (52%) or for women who are not married, the stigma of abortion remains over time and can be mea- and not planning to marrying, their sexual partner (58%).4 sured after the abortion has occurred. Ethnicity and religious affi liation are associated with nega- Although multiple validated measures of abortion tive attitudes toward abortion, especially among Latino attitudes exist, no measure of abortion stigma has been and white Catholics and white evangelical Christians.4,6 validated among women who have had abortions; in fact, Negative attitudes toward abortion are associated with only four previous studies have examined the stigma of conservative beliefs about when life begins, women’s having an abortion.12–15 In the earliest one, Weidner and sexual behavior and women’s roles in society, and with Griffi tt explored college students’ reactions to women who the perception that abortion is a marginal and unneces- have abortions and their male partners.12 The researchers sary health care practice.7,8 Taken together, these attitudes found that both male and female students said they would
Volume 45, Number 2, June 2013 79 The Stigma of Having an Abortion
distance themselves socially from someone who had been negatively affected women’s postabortion psychological involved in an abortion. In 1993, Major and Gramzow experiences.”21(p. 92) assessed abortion patients’ experiences with stigma in a A valid, reliable measure of abortion stigma can improve two-year follow-up interview using a single-item measure: our understanding of the relationship between abortion level of agreement with the statement “I have felt that I stigma and mental health, physical health, emotional would be stigmatized (looked down on) by others if they well-being and health-seeking behavior. In this article, we knew that I had an abortion.”13(p. 738) Results show that two introduce a multidimensional measure of individual-level years after an abortion, experiencing abortion stigma was abortion stigma for women who have had an abortion. We positively associated with both secrecy and suppressing then apply the scale, presenting a multivariable analysis unwanted thoughts. Women who suppressed thoughts of social and demographic characteristics associated with had an increased risk of both intrusive thoughts about the abortion stigma for women. abortion and distress about the abortion. Two more recent abortion stigma studies are highly rel- METHODS evant. The fi rst compared community- and individual- This study was conducted in multiple stages: conceptu- level stigma across Mexico, Nigeria, Pakistan, Peru and the alization, item development, cognitive interviews, survey United States in 2006 using a focus group methodology.14 implementation, scale validation and multivariable regres- The authors found that across cultures, negative attitudes sion analysis. We used STATA 12 for our analysis. Each toward abortion were associated with secrecy and selec- stage of data collection and analysis received institutional tive disclosure among women who have abortions. Also in review board approval from the University of California, 2006, Shellenberg and Tsui explored “perceived and inter- San Francisco. nalized” stigma in a national survey of abortion patients in the United States.15 They found that a majority of women Conceptualization felt that other people would look down on them because We draw on a conceptual model of abortion stigma devel- of their abortion, and half felt that they needed to keep oped by Cockrill and Nack.11 After analyzing qualitative their abortion a secret. interviews with 34 women, they identifi ed three types These studies have limitations. For example, Weidner of stigma (internalized, felt and enacted) and three types and Griffi tt examined only hypothetical scenarios with of stigma management behavior (managing the dam- college students;12 it is unclear whether the disapproval aged self, maintaining a good reputation and managing a expressed by respondents would result in social distanc- damaged reputation). Cockrill and Nack’s model11 builds ing from women who have had abortions in real life. on Herek’s model of sexual stigma, or “society’s shared Furthermore, the data are 30 years old, and cultural belief system through which homosexuality is deni- changes in social relationships and attitudes may have grated, discredited and constructed as invalid relative to occurred, especially among young people. The other three heterosexuality,”22(p. 171) as well as literature concerning the studies provide some understanding of the prevalence of management of deviance.23 stigma among women who have abortions.13–15 However, Many women who have abortions come from cultural they do not provide a valid and reliable measure for stigma or religious communities that hold negative beliefs about that considers additional dimensions of the experience, abortion and may therefore internalize negative views of including women’s negative attitudes toward themselves abortion.24 Internalized stigma can manifest as the nega- or perception of community attitudes. Finally, surveys tive views women hold toward themselves, as well as taken among abortion patients at the time of their proce- prejudicial attitudes they may hold toward other people dures cannot report on how stigma manifests over time. who are directly involved in abortion (e.g., other women, Stigma related to mental and physical illness, sexual- providers). Felt stigma describes a stigmatized individual’s ity, race and obesity has negative impacts on individuals’ perceptions of other people’s attitudes toward abortion mental and physical health, emotional well-being and and their expectations for judgment, rejection or discrimi- health-seeking behaviors.16–18 Stigma that is related to cir- nation on the basis of those attitudes. Finally, enacted cumstances or experiences that can be concealed, like hav- stigma describes actual experiences with other people that ing had an abortion, can carry additional individual costs demonstrate to women their loss of social status follow- associated with behaviors meant to manage the stigma, ing an abortion. These experiences could include gossip, such as keeping the experience secret, trying to “pass” as a name-calling, physical abuse or discrimination by health nonstigmatized person in social interactions and suppress- care providers. ing unwanted thoughts.13,19,20 An American Psychological Cockrill and Nack’s conceptual model also theorizes that Association report reviewing studies of mental health fol- women employ intrapersonal and interpersonal behavioral lowing abortion found that “the most methodologically strategies to manage the real or potential negative effects strong studies…showed that interpersonal concerns, of stigma.11 For example, in reaction to stigma, women including feelings of stigma, perceived need for secrecy, may justify or excuse the abortion, or transfer the blame to exposure to antiabortion picketing, and low perceived others. Stigma is also associated with secretive behaviors, or anticipated social support for the abortion decision, such as telling cover stories to mask the abortion or not
80 Perspectives on Sexual and Reproductive Health revealing any personal experience when abortion is a topic with stigma scale experts, we added three items assessing of conversation. In some circumstances, experiencing attitudes toward the legality of abortion, for a total pool stigma may lead to resistance strategies, such as condemn- of 61 items. ing the negative attitudes that lead to stigma and attempt- The items were grouped under eight sections: Telling ing to normalize the abortion experience for others. the People I Am Closest To, How I Was Treated, The Man Involved in My Pregnancy, My Mother (Or the Woman Item Development and Cognitive Interviews Who Raised Me), Things I Worried About, How I Felt We used Cockrill and Nack’s model11 as a framework for About Myself, My Community’s Attitudes and Beliefs, and developing our item pool. We conducted a content analy- My Attitudes and Beliefs. Twenty-one items (e.g., “I felt sis of 20 abortion stories written by women and posted ashamed”) were measured by a fi ve-level bidirectional online to help us word and order the survey questions; Likert scale (0=“strongly agree,” 1=“disagree,” 2=“neither the sites visited were Project Voice, Project Rachel, The agree nor disagree,” 3=“agree” and 4=“strongly disagree”). Experience Project, I’m Not Sorry, Rachel’s Vineyard and Eighteen items (e.g., “I have had a conversation with Pregnancy Help Now. Finally, we reviewed the literature someone that I’m close to about my abortion”) were mea- on other stigma measures25,26 and consulted with four sured by the frequency of the experience on a four-level published experts in scale validation to get feedback on unidirectional scale (0=“never,” 1=“once,” 2=“more than the items and establish face validity. We developed an ini- once” and 3=“many times”). Eleven items (e.g., “How wor- tial pool of 66 items to measure internalized stigma (seven ried were you that other people might fi nd out about your items), enacted stigma (28 items), felt stigma (14 items) abortion?”) were measured on a four-level unidirectional and stigma management strategies (17 items). The initial scale (0=“not at all worried,” 1=“a little worried,” 2=“quite pool is available from the authors upon request. worried” and 3=“extremely worried”). Seven items mea- To measure internalized stigma, we included items on suring community attitudes (e.g., “How much of your women’s feelings toward themselves following their abor- community holds the following belief: abortion is a sin?”) tion and their attitudes and beliefs about abortion. Because used a fi ve-level unidirectional scale (0=“no one,” 1=“a few abortion is a concealable social experience, we measured people,” 2=“about half the people,” 3=“many people” and felt stigma with a set of items exploring a woman’s con- 4=“most people”). Each of the remaining four items had a cerns about poor treatment or damage to her reputation unique set of 3–5 possible responses. (For details on all 61 if her abortion were to become known to others. Most items, see Supporting Information online.) women tell someone else about their abortion; there- Our fi nal three postsurvey cognitive interviews explored fore, we measured enacted stigma with items exploring a the revised items and an iPad-assisted survey design. We woman’s interactions with key people in her life (the man programmed the item pool and demographic questions involved in the pregnancy, her mother, health care pro- into iFormBuilder, a software application for conducting viders and a more general category of “other people” who self-administered surveys using iPads. Interviews were knew about her abortion). To measure stigma manage- recorded and transcribed. The fi nal version of the survey ment behaviors, we included items on how often women was translated from English into Spanish, and the transla- disclosed their abortions or sought emotional support, as tion was tested by three fl uent Spanish speakers. well as how often they concealed their abortions through omission or deception. Survey Implementation To refi ne the item pool, and assess content validity, We developed our recruitment plan with two important we conducted cognitive interviews with 14 women at considerations: timing of the abortion and confi dentiality. three family planning clinics in Northern California. The To adequately measure the three types of stigma and stigma women gave verbal informed consent and were each paid management behaviors, we wished to recruit women who $30. They were 19–44 years old and differed by race (nine had had suffi cient time to experience the effects of dis- were white, three black, one American Indian, one mixed- closing (or not disclosing) their abortion to someone else. race), ethnicity (three were Latina) and monthly income Therefore, we sought to recruit women from a general ($800–4,000). The fi rst 11 completed a paper survey that family planning clinic population and to identify those included all 66 items and then answered open-ended ques- who had had an abortion in the past. However, we did not tions aimed at determining whether the items were being want to “out” women who had previously had abortions, interpreted as intended and were being interpreted con- so abortion history was not a part of the inclusion criteria, sistently. In addition, we assessed content validity by ask- and no direct disclosures of abortion experience were nec- ing each woman to report on whether the items assessed essary for participation in this study. the full range of experiences related to abortion stigma. To address these considerations, the stigma scale study Each interview was recorded and transcribed. After ana- was implemented along with another study on contracep- lyzing these transcripts, we revised the wording on most tive attitudes. Both surveys were programmed for the iPad. items and item answers to clarify meaning, clarifi ed the Participants were not told that there were two question- survey instructions and deleted a section about postabor- naires, and only women who reported a past abortion tion medical care (eight items). Finally, in consultation received the survey about stigma. The front desk staff
Volume 45, Number 2, June 2013 81 The Stigma of Having an Abortion
New Jersey and Tennessee. We recruited from a total of TABLE 1. Results of principal components factor analysis of items assessed for the Individual Level Abortion Stigma scale 13 Planned Parenthood health centers from January 2011 Factor and items Factor until August 2011. Women were eligible if they were loading† seeking general reproductive health services, including pregnancy tests, STD tests, Pap smears and other routine Worries about judgment‡ Other people might fi nd out about my abortion 0.78 services. None of the participating clinics offered abortion My abortion would negatively affect my relationship with someone I love 0.79 services on the day of recruitment. I would disappoint someone I love 0.77 I would be humiliated 0.84 We needed to select a suffi ciently large, diverse and People would gossip about me 0.84 reasonably representative sample for conducting factor I would be rejected by someone I love 0.82 analysis on a scale. A participant-to-item ratio of 10 to 1 People would judge me negatively 0.86 Cronbach’s a =0.94 is generally considered suffi cient;27 therefore, we sought a Eigenvalue, 9.25; 33% explained variance sample of at least 610 women who had had an abortion. Isolation Of the 2,593 women who spoke with the recruiter, 2,200 I have had a conversation with someone I am close with about my abortion§,†† 0.75 (85%) agreed to participate in the study. Of these, 643 I was open with someone that I am close with about my feelings about my abortion§,†† 0.75 reported an abortion, and 627 completed the entire abor- I felt the support of someone that I am close with at the time of my abortion§,†† 0.84 tion stigma survey (29%). Five percent of these women I can talk to the people I am close with about my abortion‡‡,†† 0.48 elected to take the survey in Spanish. I can trust the people I am close to with information about my abortion‡‡,†† 0.42 When I had my abortion, I felt supported by the people I was close with‡‡,†† 0.46 Cronbach’s a =0.83 Scale Validation Eigenvalue, 3.84; 14% explained variance We explored item variability by examining a correlation Self-judgment‡‡ matrix; correlations of greater than 0.30 suggest that items I felt like a bad person 0.71 will hang well together in factors.28 To explore the variabil- I felt confi dent I had made the right decision†† 0.51 I felt ashamed about my abortion 0.70 ity of responses, we looked at the range, mean and stan- I felt selfi sh 0.62 dard deviation of each item in our pool.28 Most item means I felt guilty 0.76 Cronbach’s a =0.84 were toward the middle of response ranges, with standard Eigenvalue, 3.19; 11% explained variance deviations of around 1.0; exceptions were items measuring experiences of outright discrimination or violent behav- Community condemnation§§ Abortion is always wrong 0.77 ior, which had low means and low variability. Finally, we Abortion is the same as murder 0.72 conducted a Kaiser-Mayer Olkin test to measure sampling Cronbach’s a =0.78 29 Eigenvalue, 2.33; 8% explained variance adequacy, which produced a robust score of 0.86. Principal components factor analysis was used to Total scale: 20 items explore the variance in our sample and to selectively Cronbach’s a =0.88 reduce the number of items in the scale. We used the †After orthogonal rotation. ‡Answer options were “not worried,” “a little worried,” “quite worried” and “ex- Kaiser-Guttman criterion to evaluate eigenvalues (seeking tremely worried.” §Answer options were “never,” “once,” “more than once” and “many times.” ††Item was reverse-coded. ‡‡Answer options were “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree” eigenvalues of greater than 1) and analyzed a scree plot to and “strongly agree.” §§Answer options were “no one,” “a few people,” “about half the people,” “many select and reduce the number of factors.30 On the basis of people” and “most people.” these analyses, we determined that our scale had a four- factor structure. provided all clients with a fl yer, which stated, “This study We examined item communalities to explore the extent aims to learn more about women’s sexual relationships, to which each item in the factor shared variance with the their reproductive choices, and their experiences with underlying factor.28 More than half of the items had com- and attitudes toward family planning and abortion.” Then munalities greater than 0.50, suggesting that the extracted the front desk staff pointed out the study recruiter, who factors accounted for the majority of the variance in the was sitting in the waiting room. The recruiter provided analyzed items. Catell’s scree plot provided a visual analy- an orientation to using the iPad and was on-site to answer sis of the factors contributing to the majority of the vari- any questions women might have. Participants consented ance in our sample.28 We used orthogonal rotation to by reading (or being read) a consent form and selecting produce distinct and uncorrelated factors. After rotation, “I consent” on the iPad. Participants then answered ques- we produced another scree plot, which showed a similar tions about their demographic characteristics, including four-factor structure, with 31 items loading greater than age, race, religion, education and pregnancy history. Any 0.40 on the fi rst four factors. answers to the question “How many abortions have you We labeled our fi rst factor “worries about judgment” had?” that were greater than zero automatically initiated because it included items examining concerns about judg- the abortion stigma survey. Women who reported no abor- ment and outcomes of judgment, such as distancing, gos- tions proceeded to the contraceptive attitudes survey. All sip and visible disapproval (Table 1). The second factor, participants were paid $20. “isolation,” included items that measured the extent to To achieve regional diversity, we selected six states for which women spoke with close friends and relatives about recruitment: California, Colorado, Florida, Michigan, their abortion, and the degree to which they felt supported
82 Perspectives on Sexual and Reproductive Health by them. The third factor, “self-judgment,” included pre- TABLE 2. Coeffi cients from analyses assessing pairwise correlations between dominantly negative feelings toward oneself because of the dimensions of abortion stigma abortion. The fi nal factor, “community condemnation,” Dimension Full scale Worries about Isolation Self- Community measured a woman’s perception of the proportion of her judgment judgment condemnation community who hold strongly negative views of abortion. After extracting the factors, we followed Comrey and Full scale 1.00 Worries about judgment 0.78** 1.00 Lee’s guidelines for selecting items for factor loadings, Isolation 0.62** 0.22** 1.00 omitting those with factor loadings of less than 0.40.31 Self-judgment 0.76** 0.42** 0.23** 1.00 We sought to remove items that split evenly between fac- Community condemnation 0.43** 0.19* 0.11** 0.30** 1.00 tors. Three items loaded above 0.35 on two factors; we *p<.05. **p<.01. removed two of these. The third (“I felt ashamed about my abortion”) loaded high (0.70) on the self-judgment fac- tor and low (0.36) on the worries about judgment factor. together with the items in any of our four factors. This After analyzing the factor without this item, we decided evidence suggests that secrecy is a separate phenomenon to retain it in the self-judgment factor. Including the item that is related to, but not the same as, stigma or any of did not seem to increase the correlation between these fac- our factors. (Similarly, Major and Gramzow examined tors; it increased the overall interpretability and reliability secrecy, disclosure and stigma as related but separate of our full scale and the self-judgment factor. phenomena.13) To demonstrate internal consistency and reliability, we The secrecy question was “I withheld information about sought the highest Cronbach’s alpha possible for our full my abortion from someone that I am close with.” Answer scale and factors, removing any items that reduced the categories were “never,” “once,” “more than once” and alpha scores.28 We retained 20 items in our fi nal four- “many times.” For ease of interpretation, we dichotomized factor scale. Our fi nal alphas (0.8–0.9) reveal that our full the variable by giving a value of 0 to “never” and 1 to any scale and factors were internally consistent and reliable. answer of “once” or more. Our initial conceptualization suggested that abortion stigma is multidimensional. To test this hypothesis, we Multivariable Regression Analysis used pairwise correlations to examine the relationships Using a multivariable linear regression model that between the factors and between each factor and the accounted for clustering by clinic site, we modeled the overall scale (Table 2). As expected, the factors correlated social and demographic characteristics associated with strongly with the full stigma scale (most coeffi cients were stigma as measured by the validated scale and subscales. 0.6 or higher), yet were not strongly correlated with one We chose variables that have previously been shown to be another (coeffi cients were 0.4 or lower). Therefore, each associated with abortion incidence: age at time of abor- factor can be considered its own subscale measuring an tion, race, education, religion, religiosity and state of resi- independent dimension of stigma. dence.24 Because number of previous miscarriages, births We named the full measure the Individual Level and abortions emerged as relevant in our cognitive inter- Abortion Stigma scale (ILAS scale). The higher the score views, we explored variables measuring these character- on the ILAS scale and subscales, the greater the stigma. istics. Also, on the basis of our cognitive interviews, we Seven of the items assess positive behaviors or feelings, added a variable measuring time since most recent abor- and are therefore inversely correlated with the other 13 tion partway through data collection; data on this measure items. By reverse-coding these seven items, we ensured were collected from 437 women. We ran bivariate analyses that the scale ranges did not cross zero. Scores for the between each variable and our full scale and subscale vari- full scale and subscales were calculated by summing the ables. The fi nal multivariable model included any indepen- item scores and dividing by the number of items. Within dent variable that was associated (p<.05) with the overall the scales and subscales, there are no obvious thresholds scale or any of the subscales in our bivariate analysis. or cutoff points related to stigmatization. Thus, we rec- Because the scales are linear, beta coeffi cients represent ommend that the scales be used as continuous variables the mean difference in stigma scores between the various whenever possible. Because the subscales are not highly subgroups and the reference group, while controlling for correlated, they can be used as independent measures of the other variables in the model. Coeffi cients of greater the different dimensions of stigma. than 1.0 signify that subgroups experienced more stigma Because previous research has shown that abortion than the reference group, while coeffi cients of less than 1.0 stigma leads to secrecy about abortion,13 we tested con- signify that subgroups experienced less stigma. struct validity by using logistic regression to assess the associations between our full scale and subscales and an RESULTS independent measure of secrecy, expecting to see a posi- Sample Characteristics tive relationship between stigma and secrecy behavior. The majority of the women reporting previous abortions The secrecy item was included in our initial factor analy- were between 19 and 29 years old (Table 3, page 84). sis of items measuring stigma. However, it did not hang Thirty-nine percent of our sample were white, 30% black
Volume 45, Number 2, June 2013 83 The Stigma of Having an Abortion
Scale Scoring TABLE 3. Percentage distribution of women participating in a study of abortion stigma, by selected characteristics, Respondents’ scores were concentrated on the low end 2011 of the full scale and averaged 1.4 (Table 4). Responses to Characteristic % the isolation subscale were also concentrated on the low (N=627) end, with a mean score of 1.2, as were those on the wor- ries about judgment subscale (mean, 0.9); one-quarter of Age 15–18 5.6 respondents selected “not at all worried” for every item in 19–24 33.8 the judgment factor. By contrast, responses on the self- 25–29 24.9 judgment scale were concentrated on the high end of the 30–39 23.1 >40 12.6 scale, though the mean score was 2.0, directly in the mid- dle of the scale. The community condemnation subscale Race/ethnicity White 39.2 was the most evenly distributed of all the scales and had a Black 29.8 mean score of 1.9. Hispanic 19.5 Asian/Pacifi c Islander 5.1 Other 6.4 Scale Validity We assessed construct validity for the full scale and sub- Education
84 Perspectives on Sexual and Reproductive Health TABLE 5. Coeffi cients (and 95% confi dence intervals) from multivariable regression analyses assessing differences in mean scores on the full scale and subscales, by selected participant characteristics Characteristic Full scale Worries about Isolation Self-judgment Community judgment condemnation
Age 15–18 0.20 (–0.04–0.43) 0.34 (–0.02–0.71) 0.07 (–0.16–0.31) 0.09 (–0.45–0.62) 0.23 (–0.03–0.49) 19–24 ref ref ref ref ref 25–29 –0.17* (–0.29 to –0.04) –0.12 (–0.32–0.07) –0.08 (–0.28–0.12) –0.28** (–0.47 to –0.10) –0.24* (–0.43 to –0.05) 30–39 –0.15* (–0.29 to –0.01) –0.07 (–0.24–0.09) –0.07 (–0.24–0.10) –0.33** (–0.55 to –0.12) –0.15 (–0.41–0.10) ≥40 –0.23** (–0.40 to –0.07) –0.29* (–0.53 to –0.05) 0.12 (–0.22–0.46) –0.54** (–0.86 to –0.23) –0.06 (–0.31–0.19)
Time since abortion <1 year ref ref ref ref ref 1–4 years –0.07 (–0.20–0.06) –0.10 (–0.27–0.08) –0.04 (–0.24–0.15) –0.05 (–0.26–0.16) –0.03 (–0.39–0.34) 5–9 years 0.06 (–0.12–0.23) –0.14 (–0.36–0.07) 0.26 (–0.03–0.55) 0.10 (–0.16–0.37) –0.06 (–0.50–0.38) 10–49 years 0.09 (–0.12–0.31) 0.06 (–0.15–0.28) 0.12 (–0.24–0.48) 0.13 (–0.20–0.45) –0.21 (–0.69–0.27) Missing 0.04 (–0.10–0.18) 0.01 (–0.18–0.19) 0.10 (–0.11–0.32) 0.03 (–0.19–0.24) –0.04 (–0.38–0.30)
Race/ethnicity White ref ref ref ref ref Black –0.08 (–0.26–0.11) –0.40** (–0.62 to –0.19) 0.12* (0.01–0.24) 0.00 (–0.31–0.31) 0.19 (–0.11–0.49) Hispanic 0.14 (–0.04–0.33) 0.16 (–0.04–0.37) 0.12 (–0.05–0.28) 0.19 (–0.18–0.56) 0.07 (–0.19–0.32) Asian/Pacifi c Islander 0.01 (–0.20–0.22) 0.00 (–0.31–0.30) –0.05 (–0.23–0.13) 0.09 (–0.27–0.46) 0.07 (–0.28–0.43) Other –0.05 (–0.27–0.16) –0.06 (–0.33–0.20) –0.02 (–0.34–0.31) –0.10 (–0.37–0.16) –0.01 (–0.30–0.29)
Education Religion Protestant 0.23** (0.08–0.38) 0.26* (0.05–0.47) 0.26* (0.03–0.50) 0.20 (–0.14–0.53) 0.16 (–0.13–0.44) Catholic 0.18* (0.04–0.33) 0.13 (–0.12–0.38) 0.20* (0.01–0.38) 0.21 (–0.10–0.53) 0.28* (0.07–0.49) Other Christian 0.12 (–0.08–0.31) 0.13 (–0.17–0.44) 0.09 (–0.16–0.35) 0.21 (–0.13–0.56) –0.08 (–0.37–0.21) Other 0.15 (–0.11–0.41) 0.03 (–0.29–0.34) 0.19 (–0.05–0.43) 0.14 (–0.36–0.64) 0.31 (–0.22–0.84) Not religious/ don’t know ref ref ref ref ref Religiosity Not at all religious/ spiritual –0.14* (–0.25 to –0.03) –0.24* (–0.42 to –0.06) 0.06 (–0.12–0.24) –0.27* (–0.48 to –0.05) –0.14 (–0.45–0.17) Somewhat religious/ spiritual ref ref ref ref ref Very religious/ spiritual 0.08 (–0.02–0.17) –0.02 (–0.19–0.14) –0.05 (–0.22–0.11) 0.26* (0.07–0.45) 0.25* (0.04–0.47) Previous birth No ref ref ref ref ref Yes –0.02 (–0.10–0.05) –0.24** (–0.37 to –0.11) 0.12 (–0.01–0.26) 0.07 (–0.08–0.22) 0.06 (–0.08–0.20) *p<.05. **p<.01. Notes: Multivariable models were adjusted for clustering effects by site. ref=reference group. Race was not associated with differences in scores on religious (0.26 and 0.20, respectively). In addition, Catholic the full scale. However, black women scored lower than women scored higher on the community condemnation white women on the worries about judgment subscale subscale than women who were not religious (0.28). (coeffi cient, –0.40) and higher than white women on the Women who were not at all religious or spiritual scored isolation scale (0.12). lower on the full scale than women who were somewhat The only difference we found related to educational religious or spiritual (coeffi cient, –0.14). Religiosity was background was on the isolation subscale. Compared with also associated with differences in scores on three sub- women who completed some college, women who com- scales. Women who were not at all religious or spiritual pleted only high school scored lower (coeffi cient, –0.15). scored lower on the worries about judgment subscale than Religious denomination and religiosity were associated women who were somewhat religious (–0.24). Compared with perceptions of stigma. Women who were Protestant or with the somewhat religious group, women who were not Catholic scored higher on the full scale than women who at all religious scored lower on the self-judgment subscale were not religious (coeffi cients, 0.23 and 0.18, respectively). (–0.27) and women who were very religious or spiritual Protestant women scored higher on the worries about judg- scored higher (0.26). Finally, women who were very reli- ment subscale than women who were not at all religious gious or spiritual scored higher on the community con- (0.26). Both Protestant and Catholic women scored higher demnation subscale than women who were somewhat on the isolation subscale than women who were not at all religious (0.25). Volume 45, Number 2, June 2013 85 The Stigma of Having an Abortion Women who had had a previous birth scored lower on strongly opposed to abortion. Among religious subgroups, the worries about judgment subscale than women who white evangelical Christians have the strongest antiabor- had not (coeffi cient, –0.24). tion views, and highly religious Protestant women have a lower likelihood of having an abortion than nonreligious DISCUSSION women.4,34 Yet, one in fi ve abortion patients identify We developed a brief scale to measure four dimensions themselves as evangelical, fundamentalist or born-again of the stigma associated with having an abortion: worries Christian,24 and Catholic women have abortions at a rate about judgment, isolation, self-judgment and community similar to that of all women.34 Highly religious Christian condemnation. Each subscale is correlated with the full women have abortions; our research suggests that these scale, but not highly correlated with the other subscales. women are at the greatest risk for stigma. Thus, the subscales can be used as independent measures. Black women were less worried about judgment related The distributions of responses in our sample were concen- to abortion than white women in our sample. There are trated on the low end of our full scale and all subscales several possible explanations for this difference. Black except the one measuring self-judgment. Americans, even black Protestants, are more prochoice The fi nal scale is distinct from our original conceptual than the general population.4 Therefore, black women may model of internalized, felt and enacted stigma and stigma come from communities with less stigmatizing attitudes. management behaviors. Felt stigma split into two factors Also, some groups respond to stigma by developing self- in the fi nal scale: worries about judgment and commu- protective factors, such as attributing negative attitudes to nity condemnation. Internalized stigma became the self- prejudice, that can reduce worry about the validity of the judgment factor. We had hypothesized that internalized attitudes and concerns about the meaning of such judg- stigma would also encompass negative attitudes toward ments.18 Current research on black women in the United abortion, but the items measuring these attitudes did not States suggests that they are more likely to report and be hang together with this factor. Enacted stigma and stigma negatively affected by gendered racism rather than sexism management behaviors did not factor into our fi nal scale. or racism alone.35 More research is necessary to under- Few women reported experiencing enactments of stigma, stand how abortion stigma may interact with the multiple especially from multiple sources at once. The infrequency oppressions faced by black women. of these experiences, combined with the fact that differ- Half of the women had previously given birth, and a ent types of enactments did not occur, may explain why third had had more than one abortion. Having multiple a factor measuring enactments did not emerge from our abortions was not associated with stigma on any of the analysis. It is possible that our measure was not sensitive scales. However, women who had given birth scored lower enough to accurately measure the types of enacted stigma on the worries about judgment subscale than women who that women encounter. had never given birth. Most women who have abortions However, a new factor, consisting of perceptions and are mothers.1 We hypothesize that because motherhood is experiences of support, emerged. This factor was inversely such a valued social role, desiring an abortion for the wel- related to the rest of the items on the scale, and when we fare of existing children offers some protection against the reverse-coded its components, we understood it as a mea- sense of being judged because of an abortion. Likewise, sure of isolation. One possible explanation of the emer- the responsibilities of raising children may require so gence of this factor and the low frequency of enactments much attention that women in this group may have less in our sample follows from research suggesting that U.S. time or emotional space to be concerned with the negative women selectively disclose their abortions only to those judgments of others. who are likely to be supportive.13 (Limited and selective disclosure are common strategies for individuals facing Strengths and Limitations stigma related to HIV infection as well.32,33) Women who In contrast to previous studies, ours allowed women to perceive stigma around them have fewer opportunities for account for their experiences of stigma not only at the time disclosure and may experience more isolation. of their abortion, but also later. However, reports on past Our analyses revealed several associations between experiences can be subject to recall bias. We attempted to religion and abortion stigma. Protestant women were address this possibility in two ways. First, in our cogni- more worried about judgment and were more isolated tive interviews, we asked women to comment on how the than nonreligious women, while Catholic women were length of time since their abortion affected their memory more likely to be isolated from social support and more of the feelings and experiences associated with the event. likely to perceive their community as hostile to abortion. Women reported feeling confi dent in their ability to recall Higher levels of self-judgment and increased perception the experience of the abortion and the emotions they felt of community condemnation were found among those at the time. Once we implemented the survey, we added women with the strongest religious beliefs compared with a question asking women to report on how much time women who were only somewhat religious. Religious had passed since their abortion. Of the 437 women who treatment of abortion varies substantially; however, the responded to this question, 62% reported that their most Catholic Church and many Protestant denominations are recent abortion was within the last four years. In our 86 Perspectives on Sexual and Reproductive Health multivariable analysis, this measure was not associated REFERENCES with any dimension of stigma. 1. Jones RK and Kooistra K, Abortion incidence and access to ser- The study of abortion experiences is vulnerable to selec- vices in the United States, 2008, Perspectives on Sexual and Reproductive Health, 2011, 43(1):41–50. tive underreporting: Women who feel the most stigma may be the least likely to report their past abortions. 2. Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Underreporting of abortion varies widely and can be Gynecology, 2011, 117(6):1358–1366. highly context-dependent. Self-administered, computer- assisted designs facilitate better reporting of pregnancy 3. Jones RK, Frohwirth LF and Moore AM, “I would want to give my child, like, everything in the world”: How issues of motherhood 36–38 history. To increase reporting, we developed a recruit- infl uence women who have abortions, Journal of Family Issues, 2008, ment protocol that did not require any direct disclosure of 29(1):79–99. abortion experience, and the survey was self-administered 4. Jones RP, Cox D and Laser R, Committed to Availability, Confl icted using tablet computers. The level of abortion reporting in About Morality, Washington, DC: Public Religion Research Institute, this study (29% of women reported a history of abortion) 2011, Volume 45, Number 2, June 2013 87 The Stigma of Having an Abortion 20. Smart L and Wegner DM, The hidden costs of hidden stigma, 31. 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