CHAPTER TWO
ON THE FRONTLINE

WHAT IS PTSD?

History has witnessed strong emotional reactions to intense trauma. Wars have been a prime cause of this problem in soldiers. During World War One, it was called "shell shock." During World War Two, it was called "battle fatigue." It's also been called "combat fatigue." Currently, the technical term for it is "Post Traumatic Stress Disorder" (PTSD).

The American Psychiatric Association officially adopted the term in 1980. The basic feature is certain symptoms following a traumatic event outside the range of usual experience. See the chart for the list of symptoms.

Some scholars have proposed that women who undergo abortion have a variant of PTSD which they call Post Abortion Syndrome. Controversy rages over whether this exists or not. Some studies show that it does, others show that it appears not to, and there seems to be a high correlation between the bias of the researcher and the results. Opponents of the concept of post-abortion problems believe that proponents are trying to undermine the actual benefits of abortion. Proponents, on the other hand, believe that people who are making a profit or have an ideological commitment are trying to sweep the negative under a rug. Over 300 studies with varying outcomes have been done on this matter, and it is subject to intense debate.

However, incredibly little study has been done of the doctors, nurses, counselors, and other staff in abortion clinics and hospitals. Such studies exist, but they are very few and hard to find. In fact, if it is narrowed down to scientific studies done by researchers who don't work in the abortion field and that look at a large number of people, there are really only two.[1]

One feature of those two studies is that they were done by people with a bias in favor of abortion availability. Yet in contrast to the studies of post-aborted women, they both note the high prevalence of symptoms that fit under posttraumatic stress disorder.

The one published in 1974, before the term PTSD was adopted, noted that "obsessional thinking about abortion, depression, fatigue, anger, lowered self-esteem, and identity conflicts were prominent. The symptom complex was considered a 'transient reactive disorder,' similar to 'combat fatigue.'"[2]

The other one didn't mention the old term for PTSD, but did list symptoms: "Ambivalent periods were characterized by a variety of otherwise uncharacteristic feelings and behavior including withdrawal from colleagues, resistance to going to work, lack of energy, impatience with clients and an overall sense of uneasiness. Nightmares, images that could not be shaken and preoccupation were commonly reported. Also common was the deep and lonely privacy within which practitioners had grappled with their ambivalence."[3]

This may be an idea that is rarely heard, but it's actually not that controversial on those few occasions when it is brought up.

Abortion workers are disinclined to complain in public very often about this point. There are no definitive answers, and abortion workers themselves are entitled to those answers. There is certainly enough evidence to show that more study is warranted.

UNUSUAL DISTRESS

The first thing to establish is that the "stressor," the thing causing the stress, is in fact great enough to bring on the symptoms. Things that are merely unpleasant, or mildly traumatic but not extraordinary, are not enough. Everyone has arguments and bruises. Many have divorces and broken legs. Does performing abortions bring on more than these normal stresses? Do abortion staff ever express it that way?

Sallie Tisdale was a nurse in an abortion clinic for a time, and after she left, she wrote about her experience in Harper's magazine: "There are weary, grim moments when I think I cannot bear another basin of bloody remains, utter another kind phrase of reassurance. . . . I prepare myself for another basin, another brief and chafing loss. 'How can you stand it?' Even the clients ask. . . I watch a woman's swollen abdomen sink to softness in a few stuttering moments and my own belly flip-flops with sorrow. . . . It is a sweet brutality we practice here, a stark and loving dispassion."[4] This woman is a nurse, so she's accustomed to ordinary medicine and all its normal squeamish details. These words suggest more stress than ordinary medicine.

The American Medical News looked at a workshop at the National Abortion Federation, and ran a report called "Abortion Providers Share Inner Conflicts" (July 12, 1993): "A nurse who had worked in an abortion clinic for less than a year said her most troubling moments came not in the procedure room but afterwards. Many times, she said, women who had just had abortions would lie in the recovery room and cry, 'I've just killed my baby. I've just killed my baby.' 'I don't know what to say to these women,' the nurse told the group. 'Part of me thinks, 'Maybe they're right.'"[5] Again, this isn't the kind of remark you would normally expect from a nurse.

Dr. Hern, an abortion specialist, gave a paper to the Association of Planned Parenthood Physicians in 1978 in which he had studied his own staff. "We have produced an unusual dilemma. A procedure is rapidly becoming recognized as the procedure of choice in late abortion, but those capable of performing or assisting with the procedure are having strong personal reservations about participating in an operation which they view as destructive and violent . . . Some part of our cultural and perhaps even biological heritage recoils at a destructive operation on a form that is similar to our own, even while we may know that the act has a positive effect for a living person. No one who has not performed this procedure can know what it is like or what it means; but having performed it, we are bewildered by the possibilities of interpretation.

"We have reached a point in this particular technology where there is no possibility of denial of an act of destruction by the operator. It is before one's eyes. The sensations of dismemberment flow through the forceps like an electric current . . . The more we seem to solve the problem, the more intractable it becomes."[6] This is a doctor who is saying outright that this is unusual and stressful.

Both nurses and the doctor were still quite firm in their belief in the need for abortion at the time they made these statements. Their idea that dealing with abortion constantly was an unusual and significant stressor, more so than ordinary medicine, didn't by any means come from opposition to abortion.

RE-EXPERIENCING

Having recurrent, intrusive recollections of the trauma is one of the symptoms, as is noted in the scholarly articles quoted near the end of the last chapter.

Dr. Hern looked at the emotional reactions of his own staff. He presented a paper on this to Planned Parenthood in 1978: "Six respondents denied any preoccupation . . . outside the clinic. Several others felt that the emotional strain affected interpersonal relationships significantly or resulted in other behavior such as an obsessive need to talk about the experience."[7]

Another symptom is a sudden feeling that the event is recurring, which ordinarily would be imaginary. In this case, the actual event is recurring, over and over again. When the pace of abortions gets high enough that a dozen are done in less than two hours, the recurring is almost frenzied.

Those symptoms may not strike everyone as proving much, since a lot of people will have those kinds of problems with more minor events throughout their lives. But one symptom is unmistakable and remarkably widespread -- dreams.

Dreams are so common that a mention of them, even a slight one, can be expected in almost all presentations on the subject of abortion staff's emotional reactions.

In academic literature, for example, come these cases from an editorial discussing sessions in which abortion staff are talking about their feelings. The author supports these sessions as a way to keep abortion staff doing the work:

Their distress was typified by one nurse's dream. This involved an antique vase she had recently wished to purchase. In the dream she was stuffing a baby into the mouth of the vase. The baby was looking at her with a pleading expression. Around the vase was a white ring. She interpreted this as representing the other nurses looking upon her act with condemnation. One can clearly see the feelings of shame and guilt reflected in this dream. But more importantly, the dream shows that unconsciously the act of abortion was experienced as an act of murder. It should be noted that this nurse was strongly committed intellectually to the new abortion law. Her reaction was typical. Regardless of one's religious or philosophic orientation, the unconscious view of abortion remains the same. This was the most significant thing that was learned as a result of these sessions.[8]

In another case, several doctors looked at the emotional impact of late-term abortions, a particular technique called the D & E procedure, on staff. They published this in the American Journal of Obstetrics and Gynecology:

The two physicians who have done all the D & E procedures in our study support each other and rely on a strong sense of social conscience focused on the health and desires of the women. They feel technically competent but note strong emotional reactions during or following the procedures and occasional disquieting dreams."[9]

The same authors discussed dreams in a 1977 paper presented to the annual meeting of Planned Parenthood physicians. "As the doctor tends to take responsibility and assume guilt for the procedure, she or he may have disturbing and recurrent ruminations or dreams."[10]

The American Medical News reported this from the National Abortion Federation workshop: "They wonder if the fetus feels pain. They talk about the soul and where it goes. And about their dreams, in which aborted fetuses stare at them with ancient eyes and perfectly shaped hands and feet asking, 'Why? Why did you do this to me?'"[11]

A news item in the ObGyn News on emotional reactions to the late-term D & E procedures reports that one-fourth of the staff members reported an increase in abortion-related dreams and/or nightmares.[12]

Dr. Hern's 1978 paper recounts more dreams. "Two respondents described dreams which they had related to the procedure. Both described dreams of vomiting fetuses along with a sense of horror. Other dreams revolved around a need to protect others from viewing fetal parts, dreaming that she herself was pregnant and needed an abortion or was having a baby. . . . In general, it appears that the more direct the physical and visual involvement (i.e. nurses, doctor), the more stress experienced. This is evident both in conscious stress and in unconscious manifestations such as dreams. At least, both individuals who reported several significant dreams were in these roles."

Former abortion doctor McArthur Hill gave his story at a pro-life conference. "We used medications to try to stop the labor of women in premature labor so that the pregnancy could progress to term. Sometimes, the aborted babies were bigger than the premature ones which we took to the nursery. It was at this point that I began to have nightmares. Now, this nightmare is a recurring nightmare, and I'll share it with you. In my nightmares, I would deliver a healthy newborn baby. And I would take that healthy newborn baby, and I would hold it up. And I would face a jury of faceless people and ask them to tell me what to do with this baby. They were to go thumbs up or thumbs down, and if they made a thumbs down indication, then I was to drop the baby into a bucket of water which was present. I never did reach the point of dropping the baby into the bucket, because I'd always wake up at that point."[13]

Of the more common first-term abortions, Bernard Nathanson, speaking of the time when he was a pioneer in setting up abortion clinics, spoke of nightmares of a clinic doctor. "I also recall well being cornered by the wife of one doctor at the cocktail party we gave when the Sixty-second Street clinic opened. She drew me aside and talked in a decidedly agitated manner of the increasingly frequent nightmares her husband had been having. He had confessed to her that the dreams were filled with blood and children, and that he had latterly become obsessed with the notion that some terrible justice would soon be inflicted upon his own children in payment for what he was doing."[14]

The fate of the fetus is the most common theme, but Sallie Tisdale reports another effect. "I have fetus dreams, we all do here: dreams of abortions one after the other; of buckets of blood splashed on the walls; trees full of crawling fetuses. I dreamed that two men grabbed me and began to drag me away. 'Let's do an abortion,' they said with a sickening leer, and I began to scream, plunged into a vision of sucking, scraping pain, of being spread and torn by impartial instruments that do only what they are bidden. I woke from this dream barely able to breathe and thought of kitchen tables and coat hangers, knitting needles striped with blood, and women all alone clutching a pillow in their teeth to keep the screams from piercing the apartment-house walls. Abortion is the narrowest edge between kindness and cruelty. Done as well as it can be, it is still violence -- merciful violence, like putting a suffering animal to death."[15]

The image of the men grabbing her and forcing her through pain in private parts of her body suggests that in this dream, abortion is associated with rape.

Note that only two of these cases, Nathanson and Hill, are given by people who now oppose abortion. The remaining ones are from people who still advocated for it at the time the dreams were reported.

NUMBING

Markedly diminished interest in significant activities is a symptom of numbing, as is a more constricted expression on the face. Both of those symptoms can easily be due to other things, and can be a matter of interpretation.

Feeling detached or estranged from other people may also be due to other causes, but there's also quite a bit of evidence for it coming from abortion work. In fact, the whole set-up of doing abortions in an assembly-line fashion could well be a manifestation of this. When this is done, most commonly the doctor has no contact with the patient until her legs are up in the stirrups. Unlike most of medicine, being detached from the patient is built into the system.

Nurse Sallie Tisdale talks of numbness. "There is a numbing sameness lurking in this job; the same questions, the same answers, even the same trembling tone in the voices." The numbness is not merely in the sameness, though. "Still, I've cultivated a certain disregard. It isn't negligence, but I don't always pay attention."

It's in the nature of this kind of symptom that it will be reported more by the people that have left the field than by the people who are still in it. After all, it's part of the symptom to avoid noticing what's happening. Talking with those that have left does lead to a rich set of illustrations of the point, as the following shows.

"We don't have conversations," said Joy Davis, a former employee of Dr. Tucker. "Sometimes, the employees faint. Sometimes they throw up. Sometimes, they have to leave the room. It's just problems that we deal with, but it's not talked about."

She goes on, "if you really dwell on it, and talk about it all the time, then it gets more personal. It gets more real to you. You just don't talk about it, try not to think about it. . . . If Dr. Tucker ever caught you discussing something like that [is this right what we're doing?], he'd fire you."

"When I was active in the abortion clinics, I don't know that any of us had any feelings about anything. We didn't really have a lot of feelings about the women, about the moral issues."

Judith Fetrow worked at a clinic in San Francisco. Later, at a pro-life conference, she offered an analysis. "When I started at Planned Parenthood, I saw two types of women working at the clinic. One group were women who had found some way to deal with the emotional and spiritual toll of working abortion. The second group were women who had closed themselves off emotionally. They were the walking wounded. You could look in their eyes, and see that they were emotionally dead."[16]

A woman who worked for a doctor in Louisiana for a few months recounted an incident in a telephone conversation. "The one thing that sticks out in my mind the most, that really upset me the most, was that he had done an abortion, he had a fetus wrapped inside of a blue paper. He stuck it inside of a surgical glove and put another glove over it. He was standing in the hall, speaking with myself and two of his assistants. He was tossing the fetus up in the air, and catching it. Like it was a rubber ball. I just looked at him, and it's like, doctor, please. And he laughed. He says, 'Nobody knows what this is.'" Doctors who are accustomed to surgery which removes body parts don't generally toss those body parts around like a toy. The doctor seems to have a numbed attitude toward the fetus, an attitude of emotional anesthesia.

Luhra Tivis worked for Dr. George Tiller of Kansas, and I asked her directly about whether she saw any sign of him being detached from others. "He had this weird thing. It was a small office, there weren't that many people there. I did all of his correspondence and everything, but if I had a certain kind of a question or procedural change, I was supposed to go through my supervisor, and she would go to him. I mean, it's ridiculous, because it was a small office. And then sometimes he would circumvent that himself, and then I'd get in trouble. So it was like he was trying to hold people off, and not have to deal with any more of the staff than he absolutely had to."

This estrangement from others can be expected to have a negative impact on the quality of the medical care. As one example, Judith Fetrow reported from her former work at a San Francisco Planned Parenthood clinic. "The most horrifying complication that I witnessed was a woman who stopped breathing during the abortion. Dr. Michael Susman just walked out of the room when he was finished. Despite my telling him that the client was not breathing, he left me alone with her. When Dr. Susman was forced to return, we didn't even follow emergency protocol for that situation. It was a miracle that this woman didn't die."[17]

In her book, Blood Money, Carol Everett tells how she administered several abortion clinics in Dallas, and ended up deciding to oppose abortion. She describes a case in which the doctor telephoned and said,

"The coroner called with the results of the autopsy. The cause of death was hemorrhaging from a cervical tear." I went numb. "We could have saved [her] life!" my mind screamed. We only needed to have sutured her cervix. We had everything we needed in the clinic to save [her] life, with one exception -- a doctor willing to take the time to re-examine his patient to determine the cause of the bleeding. . . . Even a first-year intern would have checked for the source of such profuse bleeding."[18]

It's common, when telling these stories, to interpret this kind of callous disregard as just being sloppy, or as incompetence. That judgment may be more true in some cases and less true in others. But this fits into the pattern of being a symptom of Posttraumatic Stress Disorder.

AROUSAL, SLEEP, CONCENTRATION

Sallie Tisdale talks about one symptom, the exaggerated startle response. "When a deliveryman comes to the sliding glass window by the reception desk and tilts a box toward me, I hesitate. I read the packing slip, assess the shape and weight of the box in light of its supposed contents. We request familiar faces. The doors are carefully locked; I have learned to half glance around at bags and boxes, looking for a telltale sign. I register with security when I arrive, and I am careful not to bang a door. We are all a little on edge here."[19]

This is not put in a context of response to the ever-present protesters. The sentence before this paragraph bemoans that abortion is seen as "dirty work," the paragraph after talks about concerns on the fetus.

Sleep disturbances are reported occasionally, such as in Dr. Hern's 1978 paper. The woman who worked with the Louisiana doctor saw quite a bit of that problem. "Every now and again, he would come in, he would be on edge. Let me give you an example. One day . . . in between each patient, he would fall asleep. He would go in his office, and fall asleep. I told him, 'Doctor, you really need to go home and get some rest.' And he goes, 'Oh, I'm not tired, it's just your imagination'. . . . He would take like 15 minute naps between patients."

She also reports his having trouble concentrating. "There were times when he would say, like this patient, Miss so-and-so, gets this prescription, and this patient gets -- it would be all wrong, and I would have to correct him."

The report from Carol Everett's book describing how the doctor had not done a basic exam in order to come up with a diagnosis may actually have more to do with this symptom of having trouble concentrating than with estrangement from other people. The two aren't mutually exclusive, especially when these are both symptoms of the same disorder.

PREVALENCE

The studies on the question of prevalence of symptoms among abortion staff are pathetically few.

On the question of the dreams, Dr. Hern reported two out of 23 workers reported them.[20] A news item in the ObGyn News which focussed on late-term abortions said one-fourth of the workers had them.[21] Nurse Sallie Tisdale's remark that they all had them at her clinic was probably poetic license. That symptom is clearly common enough that it should be expected to arise among a good-sized group, but not among all individuals.

There is much less data for other symptoms. A lot of those symptoms are fairly subjective, and any one of them can be caused by a lot of different things. Having a professional psychologist or psychiatrist look over individual cases with these symptoms in mind has not been done for abortion staff. The studies have noted the symptoms without saying how common the symptoms are.

However, if we just look at "negative emotions" as a whole, we can get some inkling from the academic studies. The study done in 1974, which was very soon after the country-wide legalization, reported: "A total number of sixty-six questionnaires were distributed, and forty-two were returned. . . In this particular sample, almost all professionals involved in abortion work reacted with more or less negative feelings."[22] This figure comes from an article whose concern is to ease the problem in order to make abortion workers more available.

We can't state that negative emotions can be found among all abortion workers, but this one sample, with a two-thirds response rate, and taken by people whose sympathies were with abortion work, found that it could. Whether those "negative emotions" always went far enough to be diagnosed as a stress disorder is another matter.

A major government study of Vietnam veterans [23] spent a remarkable amount of time in documenting the point that veterans who had been closer to the actual combat got more stress out of it than those who had not. It should account for the gender difference since women were less likely to be in combat situations. The gender break-down is reversed in abortion practice, where the nurses are more likely to have negative reactions than the doctors. The analogy to abortion work would be whether those who are close to the actual procedure have more problems than those that are further away, like counselors, social workers, and receptionists. Do those that have contact with the fetal remains have more negative feelings than those who don't? The 1974 article noted that that had been concluded in previous studies, and that they found it themselves.

"Whether the professional had contact with the fetus significantly affected emotional reaction. Those staff members who had contact with the fetus reacted with much more discomfort to abortion work. Additionally, among the group of professionals who had fetus contact, there was very little variability in emotional response: All emotional reactions were unanimously extremely negative."[24]

The largest published study involved interviews with 130 abortion workers in San Francisco between January 1984 and March 1985. Unfortunately, the study didn't report on the prevalence of the symptoms, but only noted that they were widespread. They did take a look at differing definitions of what was going on in abortion work, and that gives a rich load of interesting information. They were not expecting to find what they found.

"Particularly striking was the fact that discomfort with abortion clients or procedures was reported by practitioners who strongly supported abortion rights and expressed strong commitment to their work. This preliminary finding suggested that even those who support a woman's right to terminate a pregnancy may be struggling with an important tension between their formal beliefs and the situated experience of their abortion work. . . .

"At this point in the research, the methodological decision was made to interview only practitioners who identified themselves as pro-choice and were committed to continuing their abortion work for at least six months. . . It was felt that these practitioners, most free of pre-existing anti-choice sentiments and most resistant to their potential influence, would provide rich insight into the current dilemmas and dynamics of legal abortion work."[25] This put the sample down to 105 workers.

Results showed that 77 percent bring up the theme of abortion as a destructive act, as destroying a living thing. As for murder: "This theme was unexpected among pro-choice practitioners yet 18% of the respondents talked about involvement with abortion this way at some point in the interview. This theme tended to emerge slowly in the interviews and was always presented with obvious discomfort." [26] That being the case, it would come up much less often on written surveys and questionnaires.

Even so, the Project Choice survey showed an interesting result along those lines. It was done from a list of 961 abortion providers, primarily just the physicians. It got a 30 percent mail-in response rate. It was not looking for PTSD symptoms specifically, and it only asked one question that really related to emotional responses to the abortion work itself. It asked whether any aspect of the abortion procedure ever caused them moral concern. As high as 38 percent responded yes.

The abortion providers were asked if they had specific symptoms, but this was put in the context of reactions to pro-life picketers, not reactions to the abortion work. About 25 percent responded that they had insomnia (sleep problems are one of the PTSD symptoms), and 23 percent reported depression. Anger (75%), nervousness (41%) and rage (41%) were also reported. Five percent reported an increase in alcohol consumption. The study was not done in such as way as to be able to separate out what the cause of those emotions was.

In talking about how abortion providers share inner conflicts, the American Medical News referred to abortion clinics as "America's most controversial battlegrounds" in a "political war." If Posttraumatic Stress Disorder is prevalent, then the term "battleground" may be more real, less of a metaphor, than is commonly thought.

Symptoms of Posttraumatic Stress Disorder, paraphrased from
DSM-IV, the psychiatrist manual:

A. TRAUMATIC EVENT

B. RE-EXPERIENCING THE TRAUMA

    1. RECURRENT, INTRUSIVE RECOLLECTIONS

    2. DREAMS

    3. SUDDEN ACTING OR FEELING THE EVENT IS RECURRING

    4. INTENSE DISTRESS AT CUES THAT RESEMBLE THE TRAUMA

    5. PHYSICAL STRESS REACTIONS TO CUES OF THE TRAUMA

C. NUMBING

    1. AVOIDING ANYTING ASSOCIATED WITH THE TRAUMA

    2. AVOIDING THINGS THAT REMIND ABOUT THE TRAUMA

    3. INABILITY TO RECALL SOMETHING IMPORTANT ABOUT THE TRAUMA

    4. MARKEDLY DIMINISHED INTEREST IN SIGNIFICANT ACTIVITIES

    5. FEELING DETACHED OR ESTRANGED FROM OTHERS

    6. CONSTRICTED AFFECT

    7. SENSE OF FORESHORTENED FUTURE

D. INCREASED AROUSAL

    1. SLEEP PROBLEMS

    2. IRRITIBILITY, OUTBURSTS OF ANGER

    3. TROUBLE CONCENTRATING

    4. HYPERVIGILANCE

    5. EXAGGERATED STARTLE RESPONSE


William Shakespeare
Henry IV, Part I, Act 2, Scene 3, Lines 40-62

A combat veteran's wife is speaking:

40 O, my good lord, why are you thus alone?
41 For what offense have I this fortnight been
42 A banish'd woman from my Harry's bed?
43 Tell me, sweet lord, what is't that takes from thee
44 Thy stomach, pleasure
45 and thy golden sleep?
46 Why dost thou bend thine eyes upon the earth,
47 And start so often when thou sit'st alone?
48 Why has thou lost the fresh blood in thy cheeks,
49 And given my treasures and my rights of thee
50 To thick-eyed musing and cursed melancholy?
51 In thy faint slumbers I by thee have watch'd,
52 And heard thee murmur tales of iron wars,
53 Speak terms of manage to thy bounding steed,
54 Cry "Courage! to the field!" And thou has talk'd
55 Of sallies and retires, of trenches, tents,
56 Of palisades, frontiers, parapets,
57 Of prisoner's ransom, and of soldiers slain,
58 And all the currents of a heady fight.
59 Thy spirit within thee hath been so at war
60 And thus hath so bestirr'd thee in thy sleep.
61 That beads of sweat have stood upon thy brow,
62 Like bubbles in a late-distrubed stream;

Explanation of symptoms by line:

40: social withdrawal and isolation
42: sexual dysfunction, reduced intimacy
44: somatic disturbances, loss of ability to experience pleasure
45: insomnia
46: depression
47: hyperactive startle reaction
48: peripheral vasoconstriction
49: loss of intimacy
50: depression
51: fragmented, vigilant sleep
52-59: traumatic dreams, reliving episodes of the trauma
60: fragmented sleep
61-62: night sweats, autonomic hyperactivity

Taken from Jonathan Shay,
Achilles in Vietnam: Combat Trauma and the Undoing of Character


Return to Table of Contents
Proceed to Chapter Three