Why do abortion "exceptions" rarely include mental health?

As more states move toward more restrictive gestational limits on when a person can have an abortion or not, medical “exceptions” have become the norm. While they often create more confusion than clarity, frequently missing from exceptions are those for mental health. More often than not, the exceptions are focused on physical health only. 

According to KFF, 14 states have near-total abortion bans. Many more have restrictions with gestational limits in effect. While exceptions vary, only one state, Alabama, explicitly includes mental health conditions as a legal exception. However, in this case, the exception specifically requires a psychiatrist to diagnose the pregnant person with a “serious mental illness” and document that the person will engage in behavior that could result in their death or the death of the fetus due to their mental health condition.

Other states, like Georgia, Florida and Idaho, explicitly exclude mental and emotional health. Tennessee’s law states: “No abortion shall be deemed authorized … on the basis of a claim or a diagnosis that the woman will engage in conduct that would result in her death or substantial and irreversible impairment of a major bodily function or for any reason relating to her mental health.”

Yet a recent report released by the Centers for Disease Control and Prevention analyzing maternal deaths between 2017 and 2019 found that pregnant and postpartum people were more likely to die from mental health-related issues than any other cause. In fact, mental health conditions accounted for 23 percent of pregnancy-related deaths with an identified cause. Hemorrhage and heart-related conditions came next, each accounting for about 13 percent. Notably, the report found that "over 80% of pregnancy-related deaths were determined to be preventable."

“Mental health is a real crisis for many people, in the same way that physical health is,” Laurie Sobel, the associate director of Women's Health Policy at KFF told Salon. “The bans, in general get in the way of people being able to access the health care they need, whether it be physical or mental health services.”

The explicit exclusion speaks to how stigmatized mental health conditions are in the United States and how especially in the abortion debate, mental health is rarely taken seriously. 

“It's one stigma on top of another: abortion is stigmatized, mental health is stigmatized — and [if] you need an abortion for a mental health issue, you're just adding stigma on stigma,” Sobel told Salon. “So it's most challenging for people in that situation to access care, and as we've already said, most of the bans have no exception for mental health at all. But at some point, mental health becomes physical health, but the physical health exceptions aren’t clear either.”

Antonia Biggs, an associate professor and social psychologist at UCSF's Advancing New Standard in Reproductive Health Program agreed. 

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“I would agree that it is rooted in a stigma that we have related to mental health, where it's not seen as a serious condition that can affect people,” Biggs said. “But there's a problem in trying to legislate which reasons for abortion are okay.”

Indeed, despite some states having exceptions for rape and incest, a January report concluded that these exceptions fail to provide reasonable access to abortion for survivors — in part because these exceptions often require survivors to report the incident to law enforcement. Experts have also long warned that “health-saving exceptions” rarely work as intended. When it comes to mental health conditions, it’s worth noting that some medications to treat psychosis or bipolar disorder, such as lithium, have an increased risk of birth defects, although the risk is considered relatively low and scientists aren't sure what causes it. Nonetheless, while clinicians are advised to discuss the need for effective contraception during treatment, unexpected pregnancies do occur even when contraception is used. 

Overall, Biggs said mental health had been a divisive part of the abortion debate in a myriad of ways. For instance, the myth that abortion can worsen mental health is frequently spread by anti-abortion advocates. But that isn’t true, Biggs said, who worked on the Turnaway Study, a longitudinal study examining the effects of unwanted pregnancy on women's lives which found that abortion isn’t linked to mental illness — though being denied one might.

“The experience of being denied an abortion and having to confront the fact that now you are going to carry this unwanted pregnancy to term is incredibly stressful and anxiety-provoking,” Biggs said. “We also have huge long-term impacts on people's lives due to abortion denial, people are more likely to live in poverty, to be financially insecure, and economic impacts extend to their children, who are also more likely to live in poverty.” 

The study also found that there were “serious physical adverse physical health consequences of being forced to carry that unintended pregnancy to term,” Biggs said.

Studies following the Dobbs decision continue to show that living in states in which tighter abortion restrictions have been enacted are more likely to report elevated levels of mental distress. While the lack of mental health exceptions speaks to a bigger problem in our society, ultimately, experts say it’s not up to lawmakers to decide which circumstances are allowed to terminate a pregnancy or not. 

“Every circumstance is so unique, it's not the place of the courts to legislate and decide which reasons are acceptable or not,” Biggs said. “I don't think that the courts have the capacity or the expertise to decide every nuanced scenario that might be accepted that they would consider acceptable.”