Men’s Perceptions Concerning Disclosure of a Partner’s Abortion: Implications for Counseling

Utilizing an online survey, adult male partners of women who underwent induced abortion were queried concerning the men’s disclosure of the experience to others. Responses were obtained from 101 men who identified positive and negative aspects related to their disclosure. Positive aspects included: relief, spiritual benefits, support, acceptance, empathy, forgiveness, helping others, acknowledgment of child, and increased understanding. Negative aspects included: lack of empathy, pain of facing reality, lack of resolution, and condemnation. For this group of men, disclosure was perceived positively more often than negatively. Implications for counseling are discussed.


Introduction
The body of literature related to men and abortion is relatively small compared to that pertaining to women (Coyle, 2006). While a number of studies have called attention to men's desire or need for counseling concerning pregnancy termination (Gordon, 1978;Lauzon, Roger-Achim, Achim, & Boyer, 2000;Myburgh, Gmeiner, & Van Wyk, 2001a;Papworth, 2011;Rodrigues & Hoga, 2006;Rothstein 1977b), none have investigated men's perceptions regarding their disclosure of the abortion experience and how those perceptions may inform counseling. This internet-based study is unique in its focus on men's assessment of both the positive and negative aspects of discussing the abortion with others. Implications for counseling are discussed.

Men and Abortion
While studies pertaining to men's experience with a partner's abortion are limited in number, they do present a consistency of findings. Notably, studies have found that most men do not perceive elective abortion to be an easy experience and without psychological stress (Gordon & Kilpatrick, 1977;Poggenpoel & Myburgh, 2002;Shostak, 1979;Shostak, 1983). Shostak and McLouth (1984) surveyed 1,000 men who accompanied their female partners for abortion and subsequently interviewed 75 of the men after abortion. These authors found that 68% of the first group and 75% of the latter group disagreed that "males involved in an abortion generally have an easy time of it" and 47% of the clinic group vs. 63% of men interviewed after abortion agreed, "that males involved in an abortion generally have disturbing thoughts about it afterward," (Shostak & McLouth, 1984, p. 115)

. Buchanan
The European Journal of Counselling Psychology ejcop.psychopen.eu | 2195-7614 andRobbins (1990) conducted a longitudinal investigation of the adult consequences for men who experienced pregnancy during their adolescence. Adult men were assessed for psychological stress and analyses revealed that "the effects of an abortion or single parenthood are statistically significant, but those who had the child and married or lived together were not significantly more distressed than those who never experienced an adolescent pregnancy," (Buchanan & Robbins, 1990, p. 420). These findings suggest the possibility of enduring psychological effects from both abortion and single parenthood.
Feelings of grief and loss seem to be especially common among men whose partners undergo induced abortion Ferguson & Hogan, 2007;Kero & Lalos, 2000;Mattinson, 1985). Clinicians Speckhard and Rue (1993) proposed that men who do not effectively process their grief may experience complicated mourning.
Closely related to anxiety is a sense of helplessness and several studies have reported feelings of helplessness among men whose partners undergo induced abortion Halldén & Christensson, 2010;Myburgh, Gmeiner, & Van Wyk, 2001b;Poggenpoel & Myburgh, 2002). Yet, in spite of feeling helpless, men seem motivated to be helpful to their partners and many attempt to support them regardless of disagreement about the abortion decision (Gordon & Kilpatrick, 1977;Halldén & Christensson, 2010;Robson, 2002;Shostak & McLouth, 1984).
A minority of studies used clinical assessment tools and only one utilized a clinical measure of traumatic stress . Authors reported that disagreement with partners about the abortion decision predicted symptoms of intrusion, hyperarousal, and meeting full diagnostic criteria for PTSD among male participants. In addition, men's perceptions of inadequate counseling predicted relationship problems and symptoms of both intrusion and avoidance. Two case studies discussed abortion as traumagenic; Holmes (2004) noted the potential for abortion to cause men to "relive traumatic childhood experiences" (p. 115) and Robson (2002) described a man who accompanied his wife during the abortion and later suffered from re-experiencing the abortion procedure.
Similarly, Lauzon et al. (2000) reported that 21% of men who remained with their partners during the abortion found it to be a traumatizing experience.

Abortion Counseling for Men
While a number of authors have identified a need for both pre-and post-abortion counseling for men (Gordon, 1978;Lauzon et al., 2000;Myburgh, Gmeiner, & Van Wyk, 2001a;Papworth, 2011;Rodrigues & Hoga, 2006;Rothstein, 1977a), only two studies (Coyle & Enright, 1997;Gordon, 1978) investigated counseling programs developed for male partners of women undergoing abortion. Gordon (1978) evaluated the efficacy of a group counseling program for men who accompanied their partners to an abortion clinic and found that counseling was associated with a significant reduction in state-anxiety. Coyle and Enright (1997) developed and tested a forgiveness therapy program for men who self-identified as having been hurt by a personal abortion experience. Participants evidenced significant increases in forgiveness as well as significant reductions in anger, anxiety, and grief. A case study by McAll and McAll (1980) discussed a male client in whom anorexia and depression were resolved following a process of mourning for and committal of his aborted child.
In spite of the recognized need to provide counseling for men, little research has focused on developing and evaluating counseling programs and abortion counseling is still not routinely available for them. Much of the postabortion counseling currently offered to men is provided through faith-based organizations and by untrained volunteers using structured Bible studies or weekend retreat programs which have not been scientifically evaluated.
Therefore, there is a need to identify effective practices related to such counseling.

Web-Based Research
Due to the fact that web-based research has become increasingly common (Skitka & Sargis, 2006), much has been learned about the advantages and disadvantages of this type of research. For example, web survey data has been found to be equivalent to that obtained from more traditional survey methods (Ballard & Prine, 2002;Hewson & Charlton, 2005;Knapp & Kirk, 2003;Robie & Brown, 2006). In fact, responses to web-based surveys have been reported to be superior in terms of clarity and completeness (Pettit, 2002;Walsh, Kiesler, Sproull, & Hesse, 1992) and are less likely to be contaminated by social desirability (Richman, Kiesler, Weisband, & Drasgow, 1999).
The inherent risks of web-based research are basically the same as those associated with more traditional research.
Those risks include inaccurate responses, failure to respond, and the influence of the wording and the ordering of survey questions on participant responses. An additional potential risk of online surveys is multiple survey submissions (Schmidt, 1997). This risk can be easily avoided through the identification of Internet protocol numbers that allow the researcher to identify surveys coming from the same respondent (Birnbaum, 2004;Gosling et al., 2004).
Ethical considerations of web-based research are also similar to those inherent in traditional research forms.
Conditions for "informed consent" may be met by providing adequate information about the study, assuring participants of confidentiality, and making it clear that submission of a survey constitutes the participant's willingness to take part in the study. When research involves sensitive or potentially painful topics, referral information for access to professional counseling should be provided. When these conditions are met and participants are assured that they can withdraw from the study at any time, the risk of psychological harm is no greater than that of paperand-pencil surveys (Kraut et al., 2004). Therefore, an online survey was deemed to be an appropriate means to investigate the very personal experience of abortion

Method Sample and Procedure
In an effort to further our understanding of men's counseling needs related to a partner's abortion, a survey was developed and posted online. Criteria for participation in this study required that a respondent be an adult male whose partner had undergone an induced abortion. Potential respondents could find the survey by performing a search using phrases such as "men and abortion" or "abortion research." In addition, crisis pregnancy centers and other organizations that offer post-abortion counseling were informed of the survey's existence. While the survey was comprised primarily of fixed response questions, it also included a few open-ended questions that allowed participants to reply in their own words. Two survey questions are the focus of this analysis and were worded as follows: "Have you spoken about your abortion experience with any of the following?" (response choices included "friend, parent, sibling, clergyperson, counselor, and other") and "What made that discussion a positive or negative experience for you?" Of the 198 adult men who participated in the larger survey study, responses for those two questions were obtained from 101 of them. The average age of this sample was 40.5 years with a range of 18 to 71 years. The time lapse since the abortion occurred ranged from one day to 43 years and only ten of the men were married to their partners at the time of abortion. Regarding ethnicity, 86% of the men were Caucasian, 6% African-American, 2% Hispanic, 1% Asian, and 5% identified as "other." Participants evidenced a fairly high level of education with over half (51%) holding a baccalaureate or higher degree and another 30% having technical training or an associate's degree. A large majority of men (85%) identified their religious affiliation as Christian.
A frequency count was made of the individuals to whom the participants disclosed. A content analysis was also performed. This research method is a widely used qualitative analytic technique used to interpret meaning from the content of text data (Hsieh & Shannon, 2005). In counseling psychology, content analysis is employed in scale development (Worthington & Whittaker, 2006) and in qualitative research (Morrow, Casteneda-Sound, & Abrams, 2012). In the present study, conventional content analysis was applied to men's comments concerning the positive and negative aspects of disclosure in an attempt to answer the research question, "What are men's perceptions concerning their disclosure of a partner's induced abortion and how might those perceptions inform counseling?" The authors carefully read and reread men's comments and then discussed and developed positive and negative thematic categories until a comprehensive list of such categories was determined. Comments were then categorized and tabulated. Results can be found in Table One.

Results
Only two of the participants did not disclose their abortion experience to anyone. Of those men who opted to disclose, all but 15 did so to more than one person. The most frequently chosen recipient of disclosure was a friend with 80 of the men making that choice. About half of the respondents confided in a counselor (51)  aspects. For this group of men, disclosure was perceived positively more often than negatively. Positive and negative aspects of disclosure with frequencies are tabulated in Table 1. A feeling of relief or release was the most frequently noted positive aspect of disclosure. One man observed that his decision to disclose allowed him to "finally release the burden that I have carried for years." Another stated that speaking to his wife and a friend "helped me to have the feeling of 'getting it off my chest.'" Still another man wrote that disclosure provided him the opportunity to "articulate grief and frustration." Spiritual benefits were the second most frequently mentioned positive aspect associated with disclosure; they were consistently described within a Christian context and, in most cases, involved disclosure to clergy. A frequent component of spiritual benefits was confession which would seem to be closely related to relief and release. More specifically, men referred to "sacramental confession" or receiving "the sacrament of reconciliation" after disclosure.
Receiving support also was noted as a benefit of disclosure. Perceptions of support were articulated as "not feeling so alone" or "knowing that people were there for me" and "knowing I wasn't alone." Empathy and understanding were appreciated from those whom the men chose to share their experience with. Several men used the specific words "empathy" and "understanding" in reference to those they disclosed to and others made statements concerning the ability of others to "relate" to their abortion experience. Acceptance or affirmation was another positive aspect of disclosure as evidenced in the following statements: "He was neutral and left his personal opinions on the issue at rest." "…knowing that the psychologist was not going to judge me or shun me." Still another positive aspect of disclosure was receiving forgiveness which was nearly always noted concomitantly with the spiritual aspect as these phrases reveal: "Sense that God has forgiven me." The European Journal of Counselling Psychology 2015, Vol. 3(2), 159-173 doi:10.5964/ejcop.v3i2.54 "…knowing that God forgives me." "Receiving confirmation that the Lord has forgiven me." "…encouragement that the soul of that baby forgives me …" Some men saw their disclosure as helpful to others. They shared their experience with the hope that, in doing so, other men would find healing or be persuaded not to make the same decisions which led to abortion. Two men found that discussing their experience with others brought them increased understanding of the abortion experience.

Negative Responses to Disclosure
There were four categories representing the negative aspects of disclosure including: lack of empathy or understanding, pain in facing reality, lack of resolution, and condemnation. A lack of empathy was cited most frequently and is readily apparent in these examples: "The guy I spoke to meant well, but he had no idea what I was going through." "No one seems to think a man has any issue regarding abortion; it is a woman's body…" "The counselor meant well, but went on to talk about how much he enjoyed his kids, even showed me baby pictures of them." The second most frequently cited negative aspect of disclosure was the pain of facing reality as expressed in the following: "I cannot bring the baby back." "… knowing I was a partner in the murder…" "Explaining to a current girlfriend why sex is unappealing to me right now." "Having to relive the emotions." "Feeling the emotions coming back up, not being able to control the emotions." Other negative aspects of disclosure were a lack of progress in grief resolution and a feeling or fear of condemnation noted by eight and six of the men respectively. A lack of resolution after disclosure was apparent in these comments: "No one I have spoken to knows what to say or do." "When I feel that I'm over it, but when I get alone again, I lose control and think on it over and over again, and I find that nothing has changed." Feelings of condemnation were evident in the following statements: "When my wife and I went for our premarital interview with her pastor, he was very disapproving of the abortion and tried to make us feel bad and guilty about it." Disclosure "made me angry at myself and in fear of God's judgment."

Discussion Including Implications for Counseling Psychology
The findings from this limited sample suggest that male disclosure of an abortion experience may occur more often than expected, and can be beneficial. The results of this study, as well as existing research, indicate the need for increased sensitivity in the counseling field to the multiple and complex realities of abortion experiences. Induced abortion may not only be conceptualized as a developmental crisis, but for some, it may be a traumatic life experience. This is particularly so when abortion is perceived as an intentionally caused human death event which carries the potential to cause intense psychological suffering and a need for counseling. Only a few years after the legalization of abortion in the United States, Mester (1978) observed, "It is suggested that the psychotherapist who is overly influenced by statistics and the sociopolitical climate and/or his own inner conflicts may unconsciously ignore or minimize the importance of an abortion experience for a specific patient in his care," (p. 98). Surely it is essential for counselors to be self-aware with all clients and particularly when counseling in a context involving a controversial cultural or political issue. Making reproductive history a standard part of the intake process may serve to more easily identify men and women who are grieving a past abortion and offer them the opportunity to process their grief with the aid of a counselor.
Given that nearly all of the men in this study chose to disclose and their predominantly positive perceptions of disclosure, it seems apparent that providing them with an opportunity to tell their stories is beneficial. Significant secrets are often borne to prevent shame or embarrassment, but the burden of doing so carries negative health consequences (Frijns & Finkenauer, 2009;Maas, Wismeijer, Van Assen, & Aquarius, 2012;Slepian, Masicampo, & Ambady, 2014). The revelation of a secret has the potential to unburden the demands of cognitive suppression efforts and trauma inhibition. Storytelling in particular may be perceived as safe as it "offers men a way into discussion of the experience which does not compromise their male roles," (McCreight, 2004, p. 332). In addition, invitation and receptivity to men's stories carry an implicit message of validation that is sadly lacking in society.
The opportunity to share one's story with an empathic counselor also facilitates catharsis, long believed to be an essential part of healing. Finally, narration or forming a coherent story of one's experiences has been found to be associated with improvements in both psychological and physical health (Pennebaker & Seagal, 1999).
Abortion may present unique stressors to men as it prevents them from acting in accordance with personal or cultural expectations. Major, Cozzarelli, Testa, and Mueller (1992) reported that men tended to blame their own character for an unplanned pregnancy. In the context of individual counseling, these authors have worked with men who expressed guilt about impregnating their partners as well as guilt that their partners had to undergo abortion. Even when men attempt to meet role expectations by containing their emotions and supporting their partners, they may still feel they have failed to protect them adequately and thus failed twice. In addition to negative effects on self-worth, men may feel shame or guilt about both pregnancy and abortion. A number of men specifically identified receiving acceptance and forgiveness as beneficial. Forgiveness therapy has been demonstrated to be efficacious for men grappling with a partner's abortion (Coyle & Enright, 1997).
While repressing their own needs and supporting their partners may be an effective means of coping in the short term, eventually men will have to address personal issues related to abortion. It is not uncommon for men to employ divergent coping strategies that might include exercise, excessive work hours, alcohol, drugs, anger and aggression, withdrawal, confrontation, or sexual behaviors. For men struggling with a negative abortion experience, these and other strategic behaviors may be tried singularly or in combination. Therefore an exploration of current and previous coping behaviors as well as their effectiveness (or lack thereof) is useful along with consideration of more effective and healthy coping strategies. Based on responses from participants in this study, healthy coping included: disclosure to an empathic individual, working on the acquisition of insight, helping others with new insight thereby using a bad experience to produce good, and finding a way to honor the lost child.
Reliable and valid measures are available to assess clients experiencing trauma symptoms and PTSD (Norris & Hamblen, 2004) including the most current diagnostic criteria in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (National Center for PTSD, 2014). In addition, counselors should screen for comorbid conditions, particularly substance abuse and depression which are the most frequent disorders accompanying PTSD (Foa, Keane, Friedman, & Cohen, 2009). Various treatment modalities have been found to be successful for patients suffering from PTSD (Foa et al., 2009) but the presence of comorbid conditions will likely require multimodal treatment. In this study, one participant noted that he was effectively treated with Eye Movement Desensitization and Reprocessing (EMDR) as described by Shapiro (2001).
Even men who don't meet diagnostic criteria for PTSD may present with clinical anxiety Gordon & Kilpatrick, 1977) evidenced by an inability to concentrate, sleep disturbances, or agitation. For some men, anger may be a presenting problem manifest in risk-taking behaviors, self-punishment, or relationship difficulties with partners, families, or co-workers. Attempts to repress such negative emotions may involve substance abuse which men are more likely to engage in than women (Greenfield, Manwani, & Nargiso, 2003;Wilsnack, Vogeltanz, Wilsnack, & Harris, 2000). Men also are at greater risk for suicide (Centers for Disease Control, National Center for Injury Control and Prevention, 2012). Furthermore, the increased risk for suicide among those with PTSD (Sareen, Houlahan, Cox, & Asmundson, 2005) and among those with subthreshold PTSD symptoms (Marshall et al., 2001) may be a serious public health concern given the large number of induced abortions performed in the United States since legalization in 1973. Therefore, screening for depression and suicidality is recommended.
Relationships may be stressed by abortion particularly when there is disagreement between partners about pregnancy outcome. The lack of equality between men and women concerning such decisions may further strain relationships. Even when partners agree to abort, relationships may suffer from a lack of trust, restricted communication about the abortion, and, in some cases, from sexual dysfunction of one or both partners. When possible, couples should take part in counseling together and be given opportunities to improve communication and rebuild trust and commitment.
Developmental challenges may be impacted by men's experience with a partner's abortion. Yet, few studies have investigated the developmental implications of induced abortion. Among adolescents and young men, identity (Erikson, 1985), autonomy (Rothstein, 1978), and intimacy (Poggenpoel & Myburgh, 2002) may be compromised.
Older men may struggle with issues related to generativity (Erikson, 1985) as well as regret that the chance to procreate has passed them by. Therefore, a comprehensive approach to counseling these men should include attention to developmental issues.
Most men will struggle with grief issues related to multiple losses and may benefit from grief counseling and/or mourning rituals. In view of society's lack of acknowledgement of men in the context of abortion, they may suffer disenfranchisement as well. Martin and Doka (2000) differentiated instrumental from intuitive or expressive grief, noting that while men may tend toward the instrumental type, counselors are advised to avoid assumptions regarding gender and determine which mode is most effective for individual clients. Clients who lean toward an instrumental approach to grief are inclined to process their grief cognitively and immerse themselves in activity while intuitive or expressive grievers tend to express their feelings and seek support from others. Professionally trained counselors may have a bias toward the superiority of the latter. There is a "general Western bias in counseling that tends to value affective expressiveness as inherently more therapeutic than cognitive or behavioral responses" (Martin & Doka, 2000, p. 2). Unfortunately, such a bias may result in a counselor's failure to recognize that a client who does not overtly emote may nonetheless be grieving effectively and coping with his loss. Therefore, while grief must be fully processed in order to avoid complicated mourning, the actual process may vary considerably from one client to another and may be inconsistent with a counselor's expectations.
Still another bias among some counselors is the commonly held view influenced by Freud (1917Freud ( /1957) that successful grieving involves letting go of or detaching from the deceased. Consistent with this view is the notion that detachment is necessary for the grieving individual to move forward and form new relationships. More recently, the concept of "continuing bonds" has been proposed by Klaas, Silverman, and Nickman (1996). Central to this concept is the idea that relationships with others, whether living or dead, influence an individual's sense of self and how he continues to live. Forward motion is dependent on the ability to integrate the past and the deceased in a meaningful way now and in the future. Participants in this study tended to think of themselves as fathers in spite of losing their child. Some stated that disclosure had value because it was a means to acknowledge the lost child and some saw the loss as motivating them to help other men avoid the same. In general, participants seemed to demonstrate a continuing bond with their unborn children even as they recognized that discussing their loss could still bring pain.
Because abortion involves a human death experience, it may raise existential and/or spiritual concerns. While some counselors may eschew discussion of spiritual issues in therapy, it is well established that religion and spirituality offer benefits "in times of crisis, trauma, and grief" (Weaver, Flannelly, Gambarino, Figley, & Flannelly, 2003, p. 215). In fact, in the case of abortion, a spiritual approach to intervention may be critical for healing. As previously noted, a number of men mentioned receiving forgiveness from a higher power and self-forgiveness as playing key roles in relieving their guilt and anxiety and in regaining a sense of worth and competency.

Conclusion
Due to the limited, self-selected sample involved in this study, broad generalizations cannot be made. The fact that only 101 of the total sample (n = 198) chose to answer the questions focused on in this report suggests that men who did so may have been motivated for reasons these authors cannot explain. Also, as the abortions took place from one day to 43 years ago, questions may be raised concerning accuracy of recall and how the passage of time may mitigate or exacerbate men's experience. Nonetheless, participants' responses provided valuable insight into men's perceptions of positive and negative aspects of disclosing a personal abortion experience.
Future research concerning men's perceptions of an abortion experience would benefit from an exploration of risk factors that may influence men's post-abortion adjustment. It is well-known that preabortion mental health, attachment to the fetus, perceived coercion to abort, lack of emotional support, holding the belief that abortion is murder, and ambivalence about the abortion decision are risk factors for adverse psychological outcomes among women following abortion (Paul et al., 2009). Future studies may confirm or disprove these factors as influencing outcomes for men as well. Other factors such as men's developmental status, quality of relationship with partner pre-and post-abortion, and men's perceptions of their reproductive roles may also be explored in terms of their association with men's mental health after abortion. Finally, the development and scientific evaluation of counseling programs for men may serve to help men to navigate and process the abortion experience more successfully.
Regardless of the circumstances of abortion, men may be forever and permanently changed by the experience.
Comprehensive, empathic counseling can help them to successfully deal with the experience and effectively integrate it into their lives. When men are acknowledged in the context of abortion, it is, by and large, in terms of how they can and should support their female partners. However, "men need to be recognized in their own right and not solely as a means of improving the abortion outcome for women," (Papworth, 2011, p. 37). Until such recognition becomes common, men are unlikely to receive counseling.
As a field, counseling psychology seeks to "help people improve their well-being, alleviate distress and maladjustment, resolve crises, and increase their ability to function better in their lives" (Society of Counseling Psychology, Division 17 of the American Psychological Association, 2014). Counseling psychologists may be especially qualified to counsel men given their "attention to both normal developmental issues and problems associated with physical, emotional, and mental disorders" (Society of Counseling Psychology, Division 17 of the American Psychological Association, 2014). Counseling psychology's broad focus (APA, 2014) encompasses all of the various challenges men may face after abortion including: threats to masculine identity, confusion regarding role expectations, relationship problems, symptoms of anxiety and trauma, grief resolution, developmental crises, and existential concerns.

Funding
The authors have no funding to report.