Countering Shame with Compassion
The Role of the Abortion Counsellor

ERIN MULLAN

“You look really familiar. Have we met before?”

The friendly young woman who is pouring for one of the wineries at the tasting event smiles as she tries to place me.

I smile back and say, “Yeah, I’ve got one of those faces that look really familiar. I hear that a lot.” I shift the conversation back to the wine. This isn’t the kind of world where I could say, “Have you had an abortion lately? I might have been your counsellor.”

I was not sure whether she had been one of my clients. Once you’ve been an abortion clinic counsellor for many years, everyone old enough to get pregnant begins to look a bit familiar. During more than twenty-five years of working in abortion and reproductive health, I have seen more than twenty thousand clients. The ever-changing river of women that flows through my counselling office reflects all the diversity of the part of the world in which I work. The one generalization I can make is about their fertility: the kind of woman who has an abortion is one who is able to get pregnant.

There is something else that these women often hold in common—the values behind the abortion decision. The most important thing I have learned in my career is this: almost all of us make the decision to end a pregnancy because we love and value children; we want to be able to be good mothers. We take a long, hard look at our lives and we realize that we are not in the place we need to be to do the best we could. We know whether we are unable to provide properly for a child, for another child, or for the children we already have. This is a decision made in a profoundly ethical and moral framework, one that is based on valuing children.

Often, during the course of a counselling session, I share this observation with clients after they have talked to me about their situation. The discussion of the decision to have an abortion may be brief and straightforward or complex and emotionally fraught. Many come to the appointment fully certain in their decision, with strong support from their partner, friends, and/or family. Some make the decision to end a pregnancy in isolation, perhaps with only a single person in their lives in whom they can confide. Some have no one to talk to, and the people at the clinic are the only ones with whom they will fully discuss their decision and their feelings about having an abortion—the only ones who hear their stories or give them support.

In our work, we normalize the abortion experience for women by countering misinformation with knowledge and shame with compassion. We practice what Alissa Perucci calls “purposeful normalization”:

When abortion care becomes normalized, we model how the experience—both for staff and patients—can be lived as a normal part of women’s reproductive health life span. In a purposefully normalizing approach, abortions and abortion work are lived as destigmatized events in women’s lives. Staff are encouraged to be proud of their work and mentored to grow and change. Patients are welcomed into the clinic and are met where they are. . . . In this approach, we live as if abortion care were completely mainstreamed, routinely available, and non-compartmentalized. This attitudinal and behavioral shift is part and parcel of the teaching of destigmatization.1

The clinic counsellor (and other staff) can play a pivotal role in a woman’s abortion experience, but relatively little has been written about what we do.2 Our work as abortion counsellors includes decision assessment, emotional support, the obtaining of informed consent, health education, and contraceptive teaching. Perhaps the most important aspects of our work, though, involve normalization, destigmatization, and ethical reframing. About one-third of Canadian women will have at least one abortion over the course of their reproductive life, but few talk about this very common experience.3 How women feel when they end a pregnancy varies tremendously. Every emotion is within the range of normal with an abortion, but the stigma that surrounds abortion increases the likelihood that a woman will feel shame or guilt or that she is somehow “bad.”

The dominant narratives in society about abortion often have little to do with women’s lived experience and too much to do with shaming women. Despite the fact that Canadians are, in the majority, pro-choice, negative and unfair attitudes toward the subject are rife in the popular discourse.4 Abortion stigma has been defined as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood.”5 The fact that abortion is a common event in women’s reproductive lives does not lessen the stigma associated with it—a phenomenon that the same authors describe as “the prevalence paradox: the social construction of deviance despite the high incidence of abortion.”6

Women can be silenced and harmed by stigma, and abortion stigma is increased by silence. Among the factors that the American Psychological Association’s 2008 Task Force on Mental Health and Abortion identified as being “predictive of more negative psychological responses following first-trimester abortion among women in the United States” are “perceptions of stigma, need for secrecy, and low or anticipated social support for the abortion decision.”7 In my experience, in addition to a woman’s confidence in her decision, having good support makes a pivotal difference in how well she copes afterwards.

Not all women feel shame about having an abortion, and some are less affected than others by abortion stigma. Cultural differences can mean that some women are outside of the influence of stigma. Women who are recent immigrants often answer the counselling session question as to how they will feel afterwards with “better,” “happy,” or “free.” Some women do not feel shame because they do not know they are “supposed to” feel bad. Abortion stigma, rather than being a universal truth, is “a social phenomenon that is constructed and reproduced locally through various pathways.”8 There are women who only feel shame when they are introduced to negative messages or judgment about abortion. Stigma is a social construct, something that is made by others. I use the metaphor of a coat when talking with clients about others’ attitudes about abortion shame. The shaming is like a coat; it is something outside of us. On the inside are the good values women use to make the decision. The coat is not theirs. It is too heavy and does not fit. Someone else is trying to get them to wear it.

I am never sure where things are going to go once I close the door to my counselling office. The women’s stories often contain similar themes, but the focus of our conversation can vary wildly. As counsellors, we see women who have no issue with their decision and our time together is spent addressing contraception and the informed consent. Much of our work involves education, answering questions about all aspects of reproductive and sexual health. We spend a tremendous amount of time correcting misinformation about abortion and contraception. Our role is to provide the most accurate information possible, so we are constantly updating our own knowledge. One of the things I love about my profession is being able to learn new things every day I work.

The context in which an abortion takes place often shapes a woman’s experience much more than the event itself.9 Having an abortion often puts a bright spotlight on everything that is good in our lives and everything that is not. For many women, this experience is a catalyst for making positive changes in their lives.

One of the hardest parts of the work is bearing witness to the horrific circumstances of some women’s lives. Hearing stories of rape or abuse is nothing compared to having lived them, but repeated exposure to others’ pain puts us at risk for vicarious trauma. Just as support is crucial for women when going through an abortion, having good support both in and outside of the workplace is key to being able to survive and thrive in this extraordinary profession.

An abortion counsellor also needs to possess a genuine and openhearted curiosity about others. In our work, we meet women of every race, language, culture, and class; few people have the opportunity that we do to meet such a wide cross-section of the population. Our clients teach us so much about their cultures and perspectives, which is a rare privilege for us. Our work teaches us how important it is to not make assumptions. I once saw a sixteen-year-old who, two years earlier, had been protesting outside our clinic, having been bussed in from her Catholic school. She told me she felt very guilty, not about having an abortion but about having been a protestor. She was absolutely certain that at age sixteen she was not ready to parent and her decision was not the issue. She felt bad about having judged others. Stories like hers underline how incredibly helpful forgiving ourselves for being human and fallible can be in moving on emotionally.

We wrestle with judgment and stigma in our counselling sessions, and we frequently encounter women’s fears about having an abortion. Our clients are often feeling hormonal, nauseous, exhausted, and terrified. They are afraid of terrible pain during the procedure and of harm to their future fertility. The two most common questions are, will it hurt and will this affect my ability to get pregnant again? As counsellors, we fight fear with knowledge and education, just as we try to reduce shame with compassion.

Some women are even afraid for their lives, like the client from Brazil whose sister back home had died from an unsafe and illegal abortion. This client fully believed that she might die in our clinic but was so determined in her decision to have an abortion that she came to her appointment anyway. Fortunately for her, abortion is incredibly safe when taken out of the backstreet. As we frequently explain to our clients, everything about this situation can be complicated, but the medical part is not. When it is done in a safe setting like the one where I work, abortion, particularly first-trimester abortion, is one of the safest medical procedures there is.

In much of the world, women are much less safe. When I think of the tens of thousands of women who die unnecessarily each year from unsafe abortions, and the millions more who are injured, it is not just an appalling abstraction. I hear those numbers and I see the faces of the women who sit across from me every day in my counselling office. Those of us who work in abortion provision are truly pro-life in that we save women’s lives and their fertility by providing access to safe abortion. We also prevent unwanted pregnancies—and future abortions—by helping women find contraceptive methods and strategies that will work for them. In the words of one woman who wrote in after her abortion to express her gratitude to the clinic she attended, “Thank you for accepting me and my choice, thank you for not judging me, thank you for listening to me and foremost thank you for protecting me.”10

Abortion counsellors prevent more abortions than anti-abortion protesters ever do. We are often the ones who recognize when the woman sitting across from us is not done with her decision and is not ready to have an abortion. We send women home when they are uncertain, saying, “This doesn’t mean that you can’t have an abortion. It just means that today isn’t the day to do it.” Often they come back; sometimes they do not. We do not have an agenda as to whether a woman should have an abortion; we are just there to be on her side. I am ever more certain that I have no idea what the woman facing me in my counselling office should do about her pregnancy. I know that I do not know. The decision is hers to make.

An unwanted pregnancy is, by its nature, an out-of-control experience, and our focus as counsellors is to give back as much control as possible to the women we see. Our form of counselling is nondirective and client-centred. I think of our role as that of a navigator: we know the terrain and have been down these roads before. The woman is in the driver’s seat, and she sets the destination.

We are often spiritual advisors. Although most of us are not conventionally religious, many of our clients are, so we talk about issues of faith every day with some of the women we see. We aid them in working through the theological and spiritual questions that arise during the decision process. I put conventional religiosity aside a very long time ago, but I have more conversations about matters of faith over the course of my work week than do most devotedly religious folk.

When people I meet ask me what I do for a living, I exercise a degree of caution. It is not that I am ashamed about what I do—far from it. I feel very fortunate to be part of this work and am proud of what we do to aid women. There is deep satisfaction in being able to help someone get through what is often a turning point in her life. It has been exciting to participate in the creation and evolution of a profession, one that evolved from the work of the women’s movement.11 But there are times when I am not at work when I would rather discuss anything else. I have little patience with people who want to tell me, often at length, their ill-informed opinions. The other reason for reticence in talking about my work is security. We know more about suspicious packages, bomb sweeps, and anthrax than most police officers do, although it is crazy that health care workers need to know about these things. Abortion providers have been injured and even killed for the work they do, and that is heartbreaking.

In the debates that rage about abortion, the counsellor’s voice is one that is seldom heard. This may be in part because of how we work—in a very private sphere. Our workdays are spent sitting across from women who come to our clinics to have abortions. For some women, the only time in their entire life that they will talk with another person about their abortion experience is during their time in the clinic. Our work carries with it the exquisite privilege of access to the interior of these women’s lives and the profound responsibility of bearing witness to their stories. By reframing the abortion decision as one that stems from ethical values, we help women lighten the weight of the abortion stigma they may be carrying. The bigger challenge is the much-needed wider societal reframing that could reduce, and someday eliminate, abortion stigma here and unsafe abortion everywhere.