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The Stigma of Having an Abortion: Development of a Scale and Characteristics of Women Experiencing Abortion Stigma

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The Stigma of Having an Abortion: Development of a Scale and Characteristics of Women Experiencing Abortion Stigma 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
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