Abortion Knowledge and Attitudes Among Psychologists and Graduate Students

Abstract

Abortion is often misunderstood and steeped in misinformation. Laypeople and medical professionals tend to have limited abortion knowledge. Among the public, individuals who hold accurate information about abortion are more likely to endorse pro-choice attitudes than individuals who are misinformed. We explored knowledge of, and attitudes toward, abortion among 142 psychologists and graduate students. Participants responded accurately, on average, to 68% of the items on a true–false measure of abortion knowledge. In addition, participants with higher levels of accurate knowledge were more likely to endorse pro-choice attitudes. Participants were especially likely to incorrectly answer items related to the prevalence, availability, and current legality of abortion in the United States. Analyzing qualitative interviews with a subset of 13 participants, we generated four themes related to knowledge and attitudes about abortion: Assuming Proficiency Despite Minimal Training, Pursuing Outside Knowledge and Training, Framing Abortion Around Identities, and Perceiving and Experiencing Consequences from Abortion Attitudes. Implications for training are delineated.

Keywords

abortion knowledge attitudes psychologists training

Although abortion is one of the most commonly performed medical procedures in the United States (Jones & Kooistra, 2011), with estimates of 1 in 4 women obtaining an abortion by age 45 (Jones & Jerman, 2017b), it remains routinely and persistently stigmatized and misunderstood (Norris et al., 2011). Stigma results in a reduction of resources, social isolation, devalued identities, and exacerbated stress (Hatzenbuehler, Phelan, & Link, 2013), a problem for anyone seeking an abortion but especially for people from marginalized groups, including poor women, women of color, rural women, and young women (Bay-Cheng, 2010). Stigma surrounding sexual and reproductive health in general, and abortion in particular, is also reflected by the paucity of scholarship on the topic within counseling psychology’s leading journals (Grzanka & Frantell, 2017).

Theorists have discussed reasons for the continued stigmatization surrounding abortion, including the violation of the tenets of women’s sexuality as tethered to motherhood (Kumar, Hessini, & Mitchell, 2009). Other scholars have identified anti-abortion attitudes such as seeing abortion as unclean or unhealthy, and perceiving abortion as violating gender norms. Additionally, some continue to use stigma to shame those seeking abortion, as well employ legal restrictions to connote amorality (Astbury-Ward, Parry, & Carnwell, 2012; Norris et al., 2011). In our study, we focused on attitudes toward the legality of abortion to explore the possibility of stigma among a sample of psychologists and psychology graduate students.

Myths about reproductive health in general, and abortion more specifically, continue to circulate and result in widespread misinformation (Matlin, 2003). For example, Bessett, Gerdts, Littman, Kavanaugh, and Norris (2015) studied a representative sample of 569 individuals in the United States and found that participants’ abortion knowledge was limited, with fewer than half of those surveyed answering five questions about abortion correctly, and almost 1 in 5 incorrectly believing abortion is illegal during the first 12 weeks of pregnancy. There were no differences in abortion knowledge dependent on whether participants lived in politically conservative, liberal, or mixed states, although individuals who knew someone who had an abortion also had more accurate knowledge; in turn, having more accurate knowledge about abortion was related to higher levels of support for it. Misperceptions and misinformation about abortion and birth control are pervasive and have been observed among women seeking abortions (Wiebe, Littman, Kaczorowski, & Moshier, 2014). In a study of more than 1,100 women in five industrialized countries, lack of knowledge was related to overestimating risks of abortion and contraception as well as favoring abortion restrictions (Wiebe, Littman, & Kaczorowski, 2015). Similarly, Kavanaugh, Bessett, Littman, and Norris (2013) found that having less accurate knowledge of abortion was related to lower support for abortion among a random sample of 639 people; they found a positive association between having more knowledge about sexuality and abortion and endorsing pro-choice attitudes.

Limited knowledge about abortion is not restricted to the general population. Considerable misinformation around abortion also has been observed among healthcare providers. Coles, Makino, and Phelps (2012) studied nearly 800 members of the Society for Adolescent Health and Medicine and found that almost one-quarter of participants incorrectly believed that medication abortion (using medication to induce an abortion) was unsafe and 40% underreported its efficacy.

Conducting a search of medical and psychology databases to determine how some organizations have “manipulated and misquoted or just ignored” scientific data, Rowlands (2011, p. 233) revealed misuse of information about abortion including making false claims about the links between abortion and breast cancer, mental health concerns, fetal pain, and women’s subsequent fertility. One source of misinformation regarding abortion is Crisis Pregnancy Centers, many of which maintain websites to dispense information about their services and abortion more generally. Bryant, Narasimhan, Bryant-Comstock, and Levi (2014) evaluated information from 254 websites representing 348 Crisis Pregnancy Centers across 12 states. They found that 80% of websites provided a minimum of one instance of false information, including asserting a deleterious relationship between abortion and mental health problems, breast cancer, future preterm births, and future fertility problems. Misinformation has also been infused in mandatory state-produced informed consent materials provided to women seeking abortion, further adding to widespread inaccurate beliefs about reproductive health. Drawing from a panel of anatomy experts, Daniels, Ferguson, Howard, and Roberti (2016) found that almost one-third of state-issued informed consent information was medically inaccurate.

Although abortion remains a common experience among women in the United States, to date no research has examined the association between abortion knowledge and attitudes toward the legality of abortion among psychologists or psychology trainees. Studies in which the authors found a positive relationship between abortion knowledge and support for pro-choice policies (Bessett et al., 2015; Kavanaugh et al., 2013; Wiebe et al., 2015) represent an important development in the link between knowledge of, and attitudes toward, abortion in the general public. However, these investigations were conducted online, which may lead to overestimating knowledge, as participants could readily look up answers to questions.

In addition, given the ubiquity of abortion, as well as the fact that it remains cloaked in secrecy and misinformation, understanding psychologists’ knowledge of and attitudes toward the legality of abortion is of critical importance, particularly among those who practice and/or are involved in training practitioners. Given that psychologists tend to espouse lower levels of religiously conservative views, and higher levels of politically progressive views compared to the general public (Bilgrave & Deluty, 1998, 2002; Inbar & Lammers, 2012), and in light of an established relationship between education and pro-choice attitudes (Wiebe et al., 2014), we expected that a majority of participants in our sample would endorse pro-choice attitudes. Conversely, given that misinformation about abortion exists even among healthcare providers (Coles et al., 2012), including faulty scholarship characterized by methodological problems that lead to erroneous conclusions about abortion and mental health (Charles, Polis, Sridhara, & Blum, 2008; Dadlez & Andrews, 2009; Russo, 2014), and in light of scholarship that shows inadequate attention to sexuality education among clinical and counseling psychologists (Burnes, Singh, & Witherspoon, 2017; Miller & Byers, 2008, 2010), we anticipated finding insufficient knowledge of abortion among our study’s participants.

To address these gaps in the literature, we collected quantitative data for our mixed-methods study at the annual meeting of the American Psychological Association and two state conferences, one in the Midwest and one in the Southwest, using a traditional paper-and-pencil measure developed specifically for this study. The qualitative portion of the data was collected via individual phone interviews. Because of the underresearched nature of abortion knowledge and attitudes among psychologists, our analyses were largely exploratory. The research questions that guided the present investigation included:

What is the level of knowledge about abortion, and what are attitudes toward the legality of abortion, held by psychologists and trainees?

Among psychologists and graduate students of psychology, is there an association between abortion knowledge and attitudes toward the legality of abortion?

What demographic factors influence psychologists’ and graduate students’ knowledge of, and attitudes toward, abortion?

What training and education about abortion do graduate training programs provide?

Method

Participants

One hundred forty-two individuals participated in the quantitative component of the study. Most identified as female (71%) and approximately half were graduate students (49%). Of the graduate students, 66% were enrolled in applied psychology programs (e.g., clinical, counseling, or school psychology), and others were in programs such as experimental, educational, social, or developmental psychology (26%); others did not identify their program (9%). Of the psychology professionals, 40% were employed doing clinical work, 28% were academic faculty, 19% did not report an occupation, and the rest reported occupations such as administration (3%) or full-time research (4%). Approximately 28% of the total sample indicated they were licensed psychologists. Participants were affiliated with 25 different Divisions of the American Psychological Association, with 44% of participants not identifying with any divisional affiliation. Divisions represented included Divisions 12 (Society of Clinical Psychology; 10 participants), 17 (Society of Counseling Psychology; 21 participants), 35 (Society for the Psychology of Women; 7 participants), 38 (Society for Health Psychology; 4 participants), 45 (Society for the Psychological Study of Culture, Ethnicity and Race; 4 participants), 50 (Society of Addiction Psychology, 5 participants), and 51 (Society for the Psychological Study of Men and Masculinities, 9 participants). Other divisions were represented by 1 or 2 participants, including Divisions 15 (Educational Psychology), 40 (Society for Clinical Neuropsychology), and 56 (Trauma Psychology).

Regarding ethnicity, 62% of the sample identified as non-Latino White, 12.7% as Black, 9.2% as Asian, 7.7% as Latino, 5.6% as multiracial, and 2.8% as other. Participants represented the following age groups: 18.3% were 18 to 24, 48.6% were 25 to 34, 23.9% were 35 to 44, 2.8% were 45 to 54, 4.9% were 55 to 64, and 1.4% were 65 years of age or older. Regarding religious affiliation, 40.8% of participants reported they were Christian, 25.4% atheist or agnostic, 14.1% other, 2.8% Jewish, 2.1% Muslim, 2.1% Hindu, and 1.4% Buddhist. The remaining 11.3% reflect those who did not answer the question about religious identification. Thirteen individuals, four professionals and nine students, participated in a follow up qualitative phone interview. They were selected by indicating their interest in a follow-up interview and responding to a follow-up email. Their ages ranged from 22 to 63 (Mdn = 29). Regarding race, participants identified as non-Latino White (n = 10), Black (n = 2), and biracial (n = 1). Eight women, four men, and one person who was questioning their gender were included in the sample. Seven identified as straight, two as gay, two as queer, one as bisexual, and one declined to disclose. Finally, regarding religion, participants identified as agnostic (n = 5), atheist (n = 4), Christian (n = 2), and other (n = 2).

Procedure

After securing Institutional Review Board approval, we collected quantitative data at psychology conferences over a 4-month period in 2016. We approached individuals at poster sessions, symposia, in the exhibit hall, during business meetings, at a divisional dinner, and at a divisional social hour and invited them to participate in a study about their knowledge of and attitudes about abortion. Of those approached, 90% agreed to participate in the study. Once they provided consent, participants completed a true–false knowledge measure, a measure of attitudes, and a demographics questionnaire. They completed the study’s materials individually and in the presence of the researcher, which allowed us to ensure they did not solicit nor acquire help or assistance on the true–false instrument. Upon completing the materials, participants were invited to indicate their interest in participating in the second phase of the study, obtaining the answers to the true–false questions, and/or receiving a summary of the findings.

We conducted individual qualitative interviews by phone over a 6-month period from September 2016 to February 2017. The second author (C. H.) emailed all participants who had indicated an interest in participating in the second phase of the study to confirm their continued interest and schedule phone interviews. Of the 45 people who had indicated interest, 13 followed through with interviews. All interviews were conducted by the second author (C. H.).

Using a thematic analysis approach (Braun & Clarke, 2006), combined with constructivist grounded theory methods (Charmaz, 2014), audio-recorded interviews were transcribed verbatim to allow the second author (C. H.) to immerse herself in the data, the first step in thematic analysis. The second step employed constructivist grounded theory’s recommendation to code line by line using gerund phrases, as thematic analysis requires a systematic coding process (Braun & Clarke, 2006). We searched for themes among the initial codes in step three. In step four, the first (D. V. M.) and second (C. H.) authors reviewed the themes as a part of developing the manuscript. The second author defined and named the themes (step five) during the initial draft of the manuscript. The completed manuscript is the result of step six, producing the report (Braun & Clarke, 2006). Pseudonyms were used in reporting participant quotes.

Measures

Because, to the best of our knowledge, no other such instrument exists, we developed a 15-item true–false instrument to assess participants’ knowledge of abortion (see Appendix A) and collected demographic information that included participants’ sex, race and ethnicity, age, religion, educational background, psychology licensure status, and specific psychological discipline(s) with which they were affiliated. All items on the true–false instrument with the exception of #14 were false. Items were developed from research findings of peer-reviewed medical and psychological studies (see, for example, Dadlez & Andrews, 2009; Fergusson, Boden, & Horwood, 2007; Jones & Koositra, 2011; Major et al., 2009; Pope, Adler, & Tschann, 2001; Raymond & Grimes, 2012) as well as national and international health and psychology organizations’ websites, including those of the World Health Organization, Centers for Disease Control, and American Psychological Association.

To assess participants’ attitudes about abortion’s legality, we adapted the Attitudes toward Abortion Questionnaire with permission from the authors (Feinberg, Antonenko, Willer, Horberg, & John, 2014a). The questionnaire contained five items regarding participants’ beliefs about whether abortion should be legal under various circumstances, such as in instances when the woman’s physical or mental health is seriously endangered by the pregnancy. Participants rated each of the five scenarios on a Likert-type scale in which 1 indicated “should definitely be legal” and 7 represented “should definitely be illegal.” Higher scores reflect beliefs that abortion should be illegal under the various circumstances specified. The questionnaire demonstrated strong internal reliability previously (α = .87; Feinberg, Antonenko, Willer, Horberg, & John, 2014b). In this study, reliability was excellent (α = .97).

We explored participants’ training and attitudes about abortion qualitatively. The follow-up qualitative interview used a semistructured protocol with five guiding questions. Questions included “How, if at all, was abortion addressed in your training program?”, “What are your personal attitudes about abortion?”, “Have you ever worked with a client around any facet of unplanned pregnancy or abortion?”, and “How do culture and context influence your attitudes about abortion?” Interviews lasted between 25 and 45 mins.

Results

Quantitative Results

The average score of correct answers on the true–false instrument was 68% (M = .68, SD = .15) with a range of 33 to 100% and a median of 10 correct answers. The average score on the abortion attitudes questionnaire was 1.84 (SD = 1.62), with a median score of 1.00. Scores ranged from 1 to 7, with lower scores reflecting more favorable attitudes toward the legal support of abortion. Participants’ abortion knowledge and attitudes were modestly and significantly correlated at r(140) = -.24, p = .004, such that having more accurate knowledge was related to endorsing more pro-choice attitudes. The results of a one-way ANOVA showed no significant differences between participants whose data were collected at the different conferences in terms of knowledge F(2, 139) = .03, p = .97, or attitudes F(2, 139) = .39, p = .67.

Item analysis revealed that, overall, participants were aware that (a) there is not an established causative relationship between abortion and breast cancer (95% of participants answered this question correctly), (b) the number of abortions performed do not decrease when it is illegal (92% correct), (c) abortion is safer than childbirth (85% correct), and (d) most women who have an abortion report a religious affiliation (85% correct). In contrast, participants were largely misinformed about the number of counties in the United States that do not have an abortion provider (16% answered correctly), the prevalence of abortion (25% correct), and the current legality of abortion in the United States (51% correct).

A one-way ANOVA based on age revealed additional differences in abortion knowledge based on age, F(5, 136) = 3.62, p = .004, with Bonferroni post-hoc tests revealing differences between age groups 18 to 24 and 35 to 44 (p = .003), and 25 to 34 and 35 to 44 (p = .03), such that the oldest of these three groups of participants scored highest on the knowledge instrument (M = .75, SD = .10), the youngest of the three groups scored lowest (M = .61, SD = .17), and the middle group scored between the two (M = .66, SD = .15). An independent samples t-test revealed significant differences in knowledge between participants who were licensed psychologists (M = .74, SD = .11) and participants who were not licensed (e.g., students and unlicensed professionals; M = .66, SD =.15; t(137) = 3.01, p = .003), such that licensed psychologists scored higher on the abortion knowledge questionnaire. No significant differences in abortion attitudes were observed based on any demographic categories. However, during the qualitative portion of the study, participants highlighted aspects of identity that informed their abortion attitudes.

Qualitative Results

We generated four themes based on the qualitative data analysis: (a) Assuming Proficiency Despite Minimal Training, (b) Pursuing Outside Knowledge and Training, (c) Framing Abortion Around Identities, and (d) Perceiving and Experiencing Consequences from Abortion Attitudes. Overwhelmingly, psychologists and students assumed the skills and attitudes developed during their training programs prepared them to work with people considering abortion. At times, participants also asserted that outside training and work experiences honed their skills for practice with clients who are considering or have had an abortion. Participants framed their attitudes about abortion, for themselves and others, around specific identities, mainly race, gender, religion, region, and social class. Largely, these attitudes were pro-choice, despite many participants disclosing they had received negative early life messages about abortion.

Assuming Proficiency Despite Minimal Training

Participants consistently stated that training programs were doing a poor job discussing abortion. All but one participant indicated that programs rarely broach the topic. A 26-year-old graduate student had this realization midinterview. He stated:

I’m in school psychology so we don’t work a lot with . . . well, I guess if we’re working with kids who, you know teenagers in high school . . . unplanned pregnancy that might be an issue, but we really haven’t talked about it that much, or if at all, to be honest.

In instances where abortion is discussed, instructors may have a difficult time facilitating the dialogues:

One of my colleagues taught a class, and for whatever reason the issue of abortion came up. . . . I know there was trouble in that class with a student calling another student a baby murderer or something horrible. . . . It was handled I think not in the greatest way . . . like basically telling the pro-life student to shut up. (33-year-old man, professional)

In this case, the instructor did not bring up the topic of abortion. Students initiated the discussion and were left to facilitate it without the instructor’s active involvement.

Another participant hypothesized that perhaps the lack of abortion training in psychology programs relates to the demographic makeup of the faculty: “Maybe it’s because socially, like, actually getting an abortion is still somewhat of a taboo topic. And because the leaders of our field and most of the department members of our program are White men.” One participant noted that the lack of training on abortion is symptomatic of minimal training around sexuality broadly. “I think the thing that’s missing overall from the program is any discussion about sexuality . . . there’s really nothing in terms of sexual behavior, sexual attitudes, sexual education, things like that” (student participant).

Despite a lack of formal training, most participants stated their basic counseling skills prepared them for working with people who may be considering an abortion, at least at a minimal level of proficiency. A 63-year-old professional said she felt “very well-prepared” because of her nonjudgmental attitudes about abortion, even though her program avoided discussions of the topic. Additionally, a participant who identified as pro-life reported feeling prepared to work with someone considering an abortion.

I had a roommate in college; his girlfriend and he had an abortion. And, while like I said, it’s not something that I would do, I totally understood his rationale behind it. I kind of talked him through it because it was pretty significant for him. So having that experience and having to talk with a friend and kind of put my bias and opinion to the side before I ever had any counseling training, that was just something I learned to do as a friend. As a counselor, I feel prepared for it now that I’ve had training. (28-year-old man, student)

Pursuing Outside Knowledge and Training

Outside training often distinguished participants who felt minimally prepared from those who felt well-prepared. Most participants desired more training than they were currently receiving or received. One participant shared that as a graduate student, he supplemented his training with articles on various topics, including abortion, when he was about to start practicum.

I remember sharing some readings . . . my peers and I were kind of going into the beginning of practicum, [wondering] what thing was going to happen that you were going to be totally unprepared for . . . so we shared some readings and . . . abortion was one of the shared readings. . . . So I think all of us got, I think, some level of exposure to the topic and some of us reading a bit more in depth about it. (33-year-old man, professional)

One participant reported that working for a sexual and reproductive health organization helped prepare her to work with clients who may seek an abortion. Another participant shared that his prior experience as a licensed counselor included working with people demonstrating high-risk sexual behaviors, which in turn prepared him to work with potential clients around abortion issues. One participant also noted that his current research is related to high-risk sexual behavior, which has further shaped his abortion knowledge and attitudes.

A participant who worked in an abortion clinic highlighted the ways that this experience broadened her knowledge and attitudes about abortion:

[Initially,] I thought, oh, these’ll be the people who’ll be in the abortion clinic multiple times frivolously using services. They would be young people, perhaps low-income . . . No, it was none of that. I mean it was some of that mixed in, but you know . . . various incomes, various ages, some people were married and were coming in with their spouses. It was just a very different experience than what I had thought. (42-year-old woman, professional)

Her early life misconceptions about the people who seek abortions shifted as a result of her training and experience working in the clinic. Similarly, other participants discussed how they framed abortion attitudes around their identities and the identities of people they thought may be seeking abortion-related services.

Framing Abortion Around Identities

Identifying as a feminist informed abortion attitudes. Additionally, identities such as race, nationality, region, class, gender, and religious affiliation also informed participants’ abortion attitudes. Participants paired endorsing a feminist identity with being pro-choice.

I identify as a feminist. I have for years, and so the sort of feminist ideal that women should be able to make the choices that they want to make, whatever those choices might be, I think that certainly impacts my attitudes towards abortion. (29-year-old woman, student)

Another participant framed abortion from a feminist perspective, stating:

The way that things are set up is that men kinda, like, dictate first of all whether or not there is access. And then they further dictate what it means if a woman does choose to get an abortion. And again, there’s that lack of recognition of any part of the male piece in this. (26-year-old woman, student)

Another participant suggested “becoming a better feminist” meant learning to be open to a pro-choice perspective, despite a conservative upbringing.

One participant reflected on her privilege as a White woman considering abortion and the differences some Black women may encounter making the same decision. She stated:

Not having the stereotypes that may come along with different people’s experience. I’m just thinking of the stereotype of the oversexed Black woman and how information about abortion would sort of intersect with that stereotype. As a White woman, I don’t experience that, so I don’t know what that feels like so, abortion just always seemed very acceptable to me. (29-year-old woman, student)

A participant supported the above statement, saying:

Most people in this country feel like it is okay for a White woman to have an abortion. So race plays a big part . . . This, ‘this woman needs to have it because she was assaulted, and it’s just too traumatic for her to raise a baby of a rape.’ But a Black woman it’s like, ‘well what did you do to get raped?’ . . . and I don’t think that only applies to Black women—I think it applies to all Brown women, honestly. (42-year-old woman, professional)

When asked about cultural context, people referenced how they were raised, often including the geographic region or neighborhood location and size as influencing their attitudes about abortion. People also referenced how region and religion intersected. Growing up liberal often meant agnostic and Northern, whereas growing up conservative often meant Catholic or Christian and Southern. Two participants who were born in a progressive country abroad noted that abortion was considered “just another medical procedure. I don’t remember all the politicization and religious pandering that happens in the United States.”

Perceiving and Experiencing Consequences from Abortion Attitudes

With one exception, all participants identified as pro-choice. However, a participant noted that even if he were not pro-choice, being in academia might dissuade him from articulating anti-abortion and/or pro-life sentiments.

I think I’m in a liberal environment [academia] where I feel like . . . if I were pro-life, I don’t know that that would be okay to say. I think that I guess I have a piece of privilege in that the attitude that I actually have is mirrored in the sort of attitude that liberal academics are supposed to have. I think that if I thought something different, I probably wouldn’t really feel comfortable talking about it. I guess I would fear being labeled as, like, sexist or antiwomen or other things like that. I’m not exactly sure what it would look like. (33-year-old man, professional)

This participant assumed that his pro-choice perspectives were widely held among psychologists, which was supported in this study. However, his perspective that it was safe to disclose pro-choice attitudes contrasted with the perspective of many participants, who suggested that abortion is not discussed in academia because the controversy surrounding abortion is largely a result of pro-life messages prevalent throughout the United States. For example, a participant shared that when moving to the Midwest from the West, she had to silence her pro-choice attitudes.

And even to the point where I am less inclined to share my views out in public living in this area just because . . . and in all fairness maybe because the way the pro-life individuals are not from where I was raised, I’d say pro-choice is a bigger deal here. You know as being [perceived as] anything from being a ‘liberal hippie’ to you know your ‘God hates you.’ (23-year-old woman, student)

Although negative messages can foreclose the possibility of having productive conversations for people who have varying views about abortion, verbal violence was discussed as being enacted only on people perceived as leaning more pro-choice. One participant shared her perceptions of how protestors reinforce pro-life messages regularly:

I saw picketers and protesters just about every day, blocking me from getting into work. They would have their whole family there, kids and everything. So those messages were, for the people that were coming into the clinic, of course to be very afraid. This is threatening. This is wrong. That someone is watching me, because they would go there because they didn’t want anyone to know, ah damn now all of these people here—what if they know me? (42-year-old woman, professional)

One participant discussed misconceptions about people who work for sexual and reproductive health organizations, including being perceived as people who “hate kids.” She indicated that she worked for one such organization when she was pregnant, which communicated a strategic message that “we’re just normal people [working for the organization].”

Perceiving and experiencing consequences from abortion attitudes also required an ongoing growth process for some participants because of the values embedded during their upbringing via media messages, schools, and the political climate. Experiences with clients and hearing balanced arguments around abortion during college allowed a participant to navigate the anti-abortion messages received during his upbringing. However, he noted that the process continues.

Cognitively, I support abortion. I think that’s the right choice for some people based on whether they think that’s the right choice for them or not about external factors, but then I also have some of that underlying memory recall . . . I suppose of the messages I had when I was a kid. And, trying to balance that against this other view that I have that it’s the right choice for some people, and so it’s an awareness that I have that I always have to make sure is balanced. I disagree with the feelings I have about it, that the, sort of the memory feelings I have about it. I don’t support those feelings, and so it’s always an interesting experience when they come up. (30-year-old man, student)

Discussion

Our study is the first to examine the association between abortion knowledge and attitudes about the legality of abortion among a diverse group of psychology graduate students and psychologists. By employing a paper-and-pencil measure for the quantitative component of our study and collecting data in person, we were able to avoid the problem of online data collection for knowledge-based measures, such that participants were unable to search for the answers to the true–false questions that comprised the measure we created for this study (Bessett et al., 2015; Coles et al., 2012; Kavanaugh et al., 2013). Accordingly, we can be fairly confident the responses to the measure assessing accurate information about abortion reflect a factual account of participants’ knowledge.

Consistent with previous research that reflects the largely politically progressive positions most psychologists endorse (Bilgrave & Deluty, 1998, 2002; Inbar & Lammers, 2012), the vast majority of the participants in the current investigation similarly endorsed pro-choice attitudes indicating support for legal access to abortion across an array of circumstances. Pro-choice attitudes were modestly correlated with having accurate knowledge about abortion, a relationship previously unstudied among psychologists but well-established in studies among the general public (Bessett et al., 2015; Kavanaugh et al., 2013; Wiebe et al., 2015). Pro-choice attitudes were also related to participants’ perceived proficiency in providing therapy to people who may consider abortion; however, it is important to note that qualitative self-reported perceptions of proficiency were not examined statistically.

Despite endorsing attitudes primarily supportive of legal access to abortion, results from the current study reflect an inadequate knowledge of abortion and a modest relationship between having accurate knowledge and endorsing pro-choice attitudes. The mean number of correct answers to the true–false measure was 68%; given that in customary practice, grades less than a B do not result in course credit in graduate programs, we assess this finding as reflective of insufficient knowledge. The stigma that characterizes abortion nationally, socially, and politically (Norris et al., 2011) may be emblematic of the relative silence in counseling psychology (Grzanka & Frantell, 2017) that results in a lack of attention in training programs and a concomitant dearth of knowledge among students and psychologists. Additionally, bias about abortion, despite legality, may influence the application of accurate knowledge in treatment of clients and patients (Hersh & Goldenberg, 2016).

Most participants answered several questions accurately. For instance, most participants understood that there is no relationship between abortion and breast cancer, that abortion rates do not decrease when abortion is illegal, that the most commonly-performed abortion is safer than childbirth, and that most women who seek an abortion report a religious affiliation. However, answers to other questions suggest an insufficient level of knowledge. For example, most participants believed that half the counties in the United States do not have an abortion provider, when 90% of U.S. counties do not have an abortion provider (Jones & Jerman, 2017a). In addition, most participants believed that 1 in 10 women in the United States will have an abortion by age 45, whereas 1 in 4 women will (Jones & Jerman, 2017b). Close to half of participants erroneously believed that abortion is currently illegal in some states. The trend in incorrect information may lead some psychologists to overestimate abortion’s accessibility while simultaneously underestimating its prevalence, which could result in inadvertently misguiding their clients who may be considering their options when facing unplanned pregnancies. Additionally, the combination of assumed proficiency and misinformation may further prevent clients from receiving accurate information about abortion during a counseling experience.

Implications for Training

People who come to psychologists for services deserve a well-prepared, informed workforce. Similarly, students who come for training deserve a thoughtfully inclusive curriculum that accurately and directly addresses experiences such as abortion that, by virtue of their prevalence and stigma, are likely to be raised by clients in therapy. Congruently, the community deserves psychologists who advocate on behalf of those who are stigmatized and politically and practically prevented from accessing services. Including abortion-related training can help destigmatize this subject for psychologists and educate our workforce on issues facing those who consider abortion among their options. Training beginning in graduate school and through continuing education can be a key touchpoint helping to deconstruct actively and intentionally negative biases about abortion in the psychology workforce. The following implications promote this advancement of our training.

For applied psychology programs, omitting training about abortion is an especially problematic oversight. Given the prevalence of abortion, it is likely that most trainees will encounter clients considering or having experienced pregnancy termination, and relying on basic counseling skills is insufficient for providing competent care. Despite stated attitudinal postures of acceptance and nonjudgment, one participant indicated that early life messages continue to influence his perspectives on abortion. Training programs can assist trainees with navigating these conflicts. Additionally, the lack of knowledge about abortion, evidenced by scores on the knowledge scale, suggest that even psychologists who have good intentions may unwittingly disseminate misinformation. Given the assumption that psychology faculty members are mostly liberal or progressive, this absence of abortion-related discussions in the training programs is glaring. Trainees may perceive the lack of discourse as a gap in their training that they must fill themselves. Additionally, depending on the training program’s location within the United States, a failure to introduce abortion discussions may silently promote the status quo, which includes placing unnecessary barriers on providers and people who may seek legal abortion services (Grzanka & Frantell, 2017).

As one participant noted, this oversight may be related to the underdeveloped sexual health training psychologists receive, as most programs do not require sexual health courses as a part of their curriculum (Burnes et al., 2017). In programs where there are sexual health courses, including abortion as a topic of discussion can help better prepare future psychologists. For students who are in or completed programs without any training related to abortion, seeking continuing education or incorporating recent research into teaching and practice are important next steps. Additionally, as advocacy is an area of competence in psychology, understanding local- and state-level politics related to abortion may provide an opportunity to serve the public interest (Grzanka & Frantell, 2017).

Additional research is needed to build upon our investigation regarding abortion, training, and professional practice. Future researchers should more specifically study training programs’ approaches to teaching students about reproductive health, including abortion as a social justice issue. Surveying training directors regarding their programs’ approaches to teaching about sexual health would further develop this area of study. Our hope is that, building on our work and the work of our colleagues (Burnes et al., 2017; Grzanka & Frantell, 2017), training guidelines can be developed in order that all programs that educate practitioners include sexual and reproductive health in their curricula, better preparing us to be advocates, especially for marginalized people whose access to sexual and reproductive health information and services is compromised.

Limitations

Although the findings of this study offer important implications for training, this study also has notable limitations. First, self-selection into a study about abortion knowledge may skew the sample. People who agree to participate in a study on abortion attitudes may be more likely to be pro-choice. Although our participants comprised a wide array of professional identities, academic foci, and disciplinary affiliations, we employed a convenience sample, which limits the generalizability of our findings. There may be discernible differences between psychologists and graduate students who attend professional meetings versus those who do not. As we knew some of the participants through our professional associations, this may also temper the study’s findings and limit their generalizability. Future researchers should purposefully recruit psychologists who identify as pro-life to assess their knowledge and attitudes about abortion. Additionally, the sample was comprised primarily of female participants, and although the gender proportion is similar to psychologists nationally (Lin, Nigrini, Christidis, & Stamm, 2015), women may have been more likely to participate given both the focus of the study and because the researchers were women. Future researchers should study attitudes toward, and knowledge about, abortion that reflect a range of participants with diverse gender identities.

Second, the study’s measures introduce limitations, particularly the true-false instrument that was developed specifically for this study. The correct answers were predominantly false, rather than representing more varied correct responses. Although based on peer-review research about abortion, the measure had not previously been validated. Additionally, due to the public nature of data collection, we did not include a question about whether participants had a personal experience with abortion that might have influenced their attitudes; researchers have demonstrated that knowing someone who has had an abortion relates positively to having more accurate knowledge about abortion (Kavanaugh et al., 2013).

Third, not all participants who completed the survey were interviewed. People who agreed to participate in the follow-up interview may have had more knowledge about abortion, and thus more confidence in their ability to answer questions thoroughly. Also, as a part of the larger study, the participants we interviewed were asked to reflect on early messages they received about abortion. These data were not included because they warrant a separate paper. The data we retained for this study reflect early messages only as they relate to current perceived competence and training. Additionally, although quantitative results reflected that older participants’ knowledge surpassed younger participants’, we did not use qualitative methods to analyze generational differences. Given the sociocultural, political, and historical developments around abortion’s legality over time, these data may have revealed compelling perspectives about participants’ attitudes.

Finally, the qualitative interviews were conducted by phone, rather than in person or via a video-conferencing medium; thus, we were not able to observe body language and nonverbal cues, which may have informed our analysis. Conducting future qualitative studies in person may enhance the interviewer–interviewee relationship and provide richer data.

In conclusion, we examined the knowledge and attitudes about the legality of abortion among psychologists and psychology graduate students across a range of disciplinary affiliations, vocational settings, and academic foci. Although most participants endorsed pro-choice attitudes, knowledge was often inaccurate, suggesting that psychologists will benefit from broadly enhancing their knowledge base around abortion, reproductive rights, and sexual health. Training is the cornerstone to effective practice, and psychologists’ values, regardless of where they fall on the spectrum regarding abortion values, cannot be considered a substitute for comprehensive and accurate education. Accordingly, it is important to prepare current trainees well and promote the continued education of licensed professionals in order that clients considering abortion have informed, empathic practitioners with whom they can discuss their options and decisions.

Footnotes

Appendix

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Debra Mollen, PhD, is professor in the counseling psychology graduate programs at Texas Woman’s University. Along with Drs. Sharon Lamb and Lillian Comas-Díaz, she is cochair of the forthcoming American Psychological Association revision of the Guidelines for Psychological Practice with Girls and Women; coauthor with Brian Baird of the forthcoming book The Internship, Practicum, and Field Placement Handbook, 8th edition (Taylor & Francis); and one of four sexuality educators in Texas certified by the American Association of Sexuality Educators, Counselors and Therapists.

Candice Hargons, PhD, studies sex, social justice, and leadership—all with a love ethic. She is an assistant professor at the University of Kentucky.

Elyssa M. Klann, MSEd, is a fourth-year counseling psychology doctoral student at Indiana University Bloomington. She is passionate about research, clinical, and advocacy work surrounding reproductive justice, the intersections of race and gender, and human sexuality.

Della V. Mosley, EdS, is a doctoral candidate at the University of Kentucky. She joined the University of Florida Counseling Psychology Program in the fall of 2018 as an assistant professor. Her research explores critical consciousness development, liberation, gender education, and sexuality with an emphasis on Black and non-monosexual queer (e.g., bisexual, pansexual) people and communities.

References

Astbury-Ward

Parry

Carnwell

(2012). Stigma, abortion, and disclosure—Findings from a qualitative study. Journal of Sex Medicine, 9, 3137–3147. doi:10.1111/j.1743-6109.2011.02604.x

Bay-Cheng

L. Y.

(2010). Justifying sex: The place of women’s sexuality on a social justice agenda. Families in Society: The Journal of Contemporary Social Services, 91, 97–103. doi:10.1606/1044-3894.3962

Bessett

Gerdts

Littman

L. L.

Kavanaugh

M. L.

Norris

(2015). Does state-level context matter for individuals’ knowledge about abortion, legality and health? Challenging the ‘red states v. blue states’ hypothesis. Culture, Health, & Sexuality, 17, 733–746. doi:10.1080/13691058.2014.994230

Bilgrave

D. P.

Deluty

R. H.

(1998). Religious beliefs and therapeutic orientations of clinical and counseling psychologists. Journal for the Scientific Study of Religion, 37, 329–349. doi:10.2307/1387532

Bilgrave

D. P.

Deluty

R. H.

(2002). Religious beliefs and political ideologies as predictors of psychotherapeutic orientations of clinical and counseling psychologists. Psychotherapy: Theory, Research, Practice, Training, 39, 245–260. doi:10.1037/00333204.39.3.245

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. doi:10.1191/1478088706qp063oa

Bryant

A. G.

Narasimhan

Bryant-Comstick

Levi

E. E.

(2014). Crisis pregnancy center websites: Information, misinformation, and disinformation. Contraception, 90, 601–605. doi:10.1016/j.contraception.2014.07.003

Burnes

T. R.

Singh

A. A.

Witherspoon

R. G.

(2017). Graduate counseling psychology training in sex and sexuality: An exploratory analysis. The Counseling Psychologist, 45, 470–486. doi:10.1177/0011000017714765

Charles

V. E.

Polis

C. B.

Sridhara

S. K.

Blum

R. W.

(2008). Abortion and long-term mental health outcomes: A systematic review of the evidence. Contraception, 78, 436– 450. doi:10.1016/j.contraception.2008.07.005

10.

Charmaz

. (2014). Constructing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.

11.

Coles

M. S.

Makino

K. K.

Phelps

(2012). Knowledge of medication abortion among adolescent medicine providers. Journal of Adolescent Health, 50, 383–388. doi:10.1016/j.jadohealth.2011.07.014

12.

Dadlez

E. M.

Andrews

W. L.

(2009). Post-abortion syndrome: Creating an affliction. Bioethics, 24, 445–452. doi:10.1111/j.1467-8519.2009.01739.x

13.

Daniels

C. R.

Ferguson

Howard

Roberti

(2016). Informed or misinformed consent? Abortion policy in the United States. Journal of Health Politics, Policy, and Law, 41, 181–209. doi:10.1215/03616878-3476105

14.

Feinberg

Antonenko

Willer

Horberg

E. J.

John

O. P.

(2014a). Attitudes toward Abortion Questionnaire [Database record]. Retrieved from PsycTESTS. doi:10.1037/t37142-000

15.

Feinberg

Antonenko

Willer

Horberg

E. J.

John

O. P.

(2014b). Gut check: Reappraisal of disgust helps explain liberal-conservative differences on issues of purity. Emotion, 14, 513–521. doi:10.1037/a0033727

16.

Fergusson

D. M.

Boden

J. M.

Horwood

L. J.

(2007). Abortion among young women and subsequent life outcomes. Perspectives on Sexual and Reproductive Health, 39, 6–12. doi:10.1363/3900607

17.

Grzanka

P. R.

Frantell

K. A.

(2017). Counseling psychology and reproductive justice: A call to action. The Counseling Psychologist, 1–27. doi:10.1177/0011000017699871

18.

Hatzenbuehler

M. L.

Phelan

J. C.

Link

B. G.

(2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103, 813–821. doi:10.2105/AJPH.2012.301069

19.

Hersh

E. D.

Goldenberg

M. N.

(2016). Democratic and republican physicians provide different care on politicized health issues. Proceedings of the National Academy of Sciences USA, 113, 11811–11816. doi:10.1073/pnas.1606609113

20.

Inbar

Lammers

(2012). Political diversity in social and personality psychology. Perspectives on Psychological Science, 7, 496–503. doi:10.1177/1745691612448792

21.

Jones

R. K.

Jerman

(2017a). Abortion incidence and service availability in the United States, 2014. Perspectives on Sexual and Reproductive Health, 49, 17–27. doi:10.1363/psrh.12015

22.

Jones

R. K.

Jerman

(2017b). Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014. American Journal of Public Health, 107, 1904–1909. doi:10.2105/AJPH.2017.304042

23.

Jones

R. K.

Kooistra

(2011). Abortion incidence and access to services in the United States, 2008. Perspectives on Sexual and Reproductive Health, 43, 41–50. doi:10.1363/4304111

24.

Kavanaugh

M. L.

Bessett

Littman

L. L.

Norris

(2013). Connecting knowledge about abortion and sexual and reproductive health to belief about abortion restrictions: Findings from an online survey. Women’s Health Issues, 23, e239–e247. doi:10.1016/j.whi.2013.04.003

25.

Kumar

Hessini

Mitchell

E. M. H.

(2009). Conceptualising abortion stigma. Culture, Health, & Sexuality, 11, 625–7639. doi:10.1080/13691050902842741

26.

Lewis

L. J.

(2004). Examining sexual health discourses in a racial/ethnic context. Archives of Sexual Behavior, 33, 223–234. doi:10.1023/B:ASEB.0000026622.31380.b4

27.

Lin

Nigrini

Christidis

Stamm

(2015). Demographics of the U.S. psychology workforce: Findings from the American Community Survey. Retrieved from http://www.apa.org/workforce/publications/13-demographics/report.pdf

28.

Major

Appelbaum

Beckman

Dutton

M. A.

Russo

N. F.

West

(2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 64, 863–890. doi:10.1037/a0017497

29.

Matlin

M. W.

(2003). From menarche to menopause: Misconceptions about women’s reproductive lives. Psychology Science, 45, 106–122.

30.

Miller

S. A.

Byers

E. S.

(2008). An exploratory examination of the sexual intervention self-efficacy of clinical psychology graduate students. Training and Education in Professional Psychology, 2, 137–144. doi:10.1037/1931-3918.2.3.137

31.

Miller

S. A.

Byers

E. S.

(2010). Psychologists’ sexual education and training in graduate school. Canadian Journal of Behavioural Science, 42, 93–100. doi:10.1037/a0018571

32.

Norris

Bessett

Steinberg

J. R.

Kavanaugh

M. L.

De Zordo

Becker

(2011). Abortion stigma: A reconceptualization of constituents, causes, and consequences. Women’s Health Issues, 21, S49–S54. doi:10.1016/j.whi.2011.02.010

33.

Pope

L. M.

Adler

N. E.

Tschann

J. M.

(2001). Postabortion psychological adjustment: Are minors at increased risk? Journal of Adolescent Health, 29, 2–11. doi:10.1016/s1054-139x(01)00212-9

34.

Raymond

E. G.

Grimes

D. A.

(2012). The comparative safety of legal induced abortion and childbirth in the United States. Obstetrics & Gynecology, 119, 215–219. doi:10.1097/aog.0b013e318258c833

35.

Rowlands

(2011). Misinformation on abortion. The European Journal of Contraception and Reproductive Health Care, 16, 233–240. doi:10.3109/13625187.2011.570883

36.

Russo

N. F.

(2014). Abortion, unwanted childbearing, and mental health. Salud Mental, 37, 283–291. doi:10.17711/SM.0185-3325.2014.033

37.

Wiebe

E. R.

Littman

Kaczorowski

(2015). Knowledge and attitudes about contraception and abortion in Canada, U.S., U.K., France, and Australia. Gynecology & Obstetrics, 5, 1–9. doi:10.4172/2161-0932.1000322

38.

Wiebe

E. R.

Littlman

Kaczorowski

Moshier

E. L.

(2014). Misperceptions about the risks of abortion in women presenting for abortion. Journal of Obstetrics and Gynaecology, 36, 223–230. doi:10.1016/s1701-2163(15)30630-7