COMMENTARY

Rape, Pregnancy, and Mental Health: What the Politics Ignores

Pooja Lakshmin, MD

Disclosures

September 16, 2019

This year we've seen a slew of restrictive reproductive laws pass in state legislatures. These pieces of legislation, passed in Alabama, Ohio, Louisiana, Mississippi, and Missouri, go further than prior legal code to forbid abortion, even in cases of rape or incest.

The Georgia "heartbeat bill" allows physicians to perform abortion up to 20 weeks into pregnancy in cases of rape or incest, but only if the victim files police charges. While these laws have not yet taken effect, legislators have acknowledged they are designed to persuade the Supreme Court to reconsider Roe v. Wade, the 1972 legal case that protects Americans' right to abortion.

I'm a psychiatrist specializing in women's mental health and perinatal psychiatry. I am concerned that these bills, intended to restrict abortion access, will adversely impact the mental health of women who have become pregnant as a result of rape and families that go on to raise children under these circumstances.

As it stands, when faced with parenting a child born of rape, women often have little respite from ongoing interaction with their rapists.

Though anti-abortion groups cite the psychological hazards of abortion, the American Psychological Association's Task Force on Mental Health and Abortion states that the strongest predictor of post-abortion mental health outcomes is a patient's prior mental health. Compared with women receiving an abortion, women who are denied the procedure can experience more symptoms of anxiety and low self-esteem.

Given what we know about the prevalence of sexual violence and the impact of sexual trauma on mental health, abortion restrictions are certain to affect the mental health of women. Nearly 1 in 3 women in the United States experience some form of sexual violence in their lifetime. Post-traumatic stress disorder (PTSD) rates in rape survivors range from 30% to 94%, and sexual violence predicts the development of PTSD more than any other trauma, including physical attacks or natural disasters.

Research on how many rapes lead to pregnancy is difficult to come by. Data from a 2010-2012 survey, the only national rape-related pregnancy prevalence study to occur in two decades, indicate that almost 2.9 million US women experience rape-related pregnancy during their lifetime. A 1996 study published in the American Journal of Obstetrics and Gynecology found that approximately 5% of all reported rapes in adult women result in pregnancy, with approximately 50% of victims choosing abortion, 30% parenting the child, and 6% pursuing adoption. A disproportionate number of these pregnancies occur in adolescents. About one third of rape victims are not aware of the pregnancy until the second trimester, when termination will be illegal under most of the new laws.

By definition, a rape-related pregnancy is unintended. In general, women who experience unintended pregnancy go on to have worse mental health outcomes, experience higher rates of perinatal mortality and postpartum complications, and are more likely to deliver low–birth weight infants.

What are the options for a woman who is raped and becomes pregnant? A 2019 paper by Connie J. Beck, PhD, a psychologist at the University of Arizona, looks at legislation, parental rights, and health outcomes for victims. Beck reports that while 39 states have legislation regarding termination of rapists' parental rights, 31 states require a criminal conviction of rape to secure a termination of rights. A criminal conviction involves proof beyond a reasonable doubt, the most difficult level of evidence to obtain. Approximately 70% of rapes are committed by perpetrators known to the victim, such as current or former partners. Seeking abortion for an unwanted pregnancy conceived via rape can be a means of escaping a violent relationship. One path toward safety will be removed for women if the newly proposed laws take effect.

In that scenario, pregnant women coping with depression and PTSD will be limited to two choices: adoption or raising the child. As it stands, when faced with parenting a child born of rape, women often have little respite from ongoing interaction with their rapists. Revoking parental rights involves a litany of court proceedings. If a woman does not press charges, she is faced with custody battles and co-parenting with her rapist. Either option costs years of emotional and financial stress as well as further exposure to violence and trauma.

We must consider the context of intimate partner violence (IPV) when evaluating consequences of pregnancy by rape. IPV is associated with unintended pregnancy, fetal or infant loss, preterm labor, and low birth weight. There is little research looking at specific health outcomes for women who are raped and decide to parent. A 2005 study of 148 women experiencing IPV found that 20% of women experienced pregnancy by rape. When comparing women who did and did not become pregnant as a result of rape, pregnant women had significantly more PTSD symptoms and higher rates of sexually transmitted diseases, genito-pelvic injuries, and infections. A 2014 study of female military members found that pregnancy after rape was associated with self-harm as an attempt to self-terminate pregnancy, as well as feelings of isolation and loss of self. Women who gave birth reported disconnection with infants, with one woman describing homicidal thoughts toward her baby.

Not only does continued contact with her rapist decrease a woman's ability to recover from trauma, but children of rape are also at risk for continued exposure to violence, and have higher rates of cognitive and emotional difficulties. A long-term study following abused women and their children for 7 years found a significant association between the abuse experience of mothers and their children's behavioral functioning.

When rape results in pregnancy, it is particularly dangerous for women. Women who are being raped by their partners are at higher risk of being killed by them too. Perpetrators of IPV can use pregnancy to force women to stay in violent relationships.

The mental health of American women needs to be considered as abortion access shrinks. The American Psychiatric Association, along with five other national physicians' groups, issued a statement calling on politicians to end their interference in the delivery of evidence-based medical care. In a country with a shortage of psychiatrists and a devastating lack of access to mental health services, I worry that these laws will disproportionately affect the most vulnerable women.

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