What are We Forgetting? Sexuality, Sex, and Embodiment in Abortion Research

ABSTRACT

Abortion has been alternately legalized and criminalized, tacitly approved of, and stigmatized, in various settings over time. The contours of its treatment are dependent on social and political contexts, including concern over women’s sexuality, but it is not clear that existing conceptual frameworks enable expansive examination of the relationship between abortion and sexuality. We conduct a critical interpretive synthesis review of the literature that jointly engages with sexuality and abortion, focusing on the U.S., to highlight the frameworks that authors use to understand the relationship between the two. We find two conceptual frameworks of abortion and sexuality in operation: one that treats the two as discrete, causal variables that operate at the individual level; and another that focuses on how beliefs about what constitutes (in)appropriate sexuality explain ideological positions on abortion. We identify limitations of both frameworks and propose a new conceptual framework – one that highlights sexual embodiment – to inspire future research in this area and generate opportunities for knowledge extension. Such an approach, we contend, can elucidate broader social forces that shape both abortion and sexuality and bring research on abortion into conversation with recent scholarship on the important role of sexuality in other sexual and reproductive domains.

Introduction

Abortion is common worldwide, with current estimates that approximately one in four pregnancies end in abortion (Sedgh et al., 2016). It is also commonly socially and politically contested. Abortion has been alternately legalized and criminalized, tacitly approved of, and stigmatized, in various settings over time, with the contours of its treatment dependent on social context. In the United States (U.S.), while certainly not the only concern framing discussions of abortion, concern over women’s sexuality has played a central role in the construction of meanings about abortion and efforts to restrict access (Reagan, 1997). Over the past century and a half, demonizing women’s sexuality has been an important element of the effort to criminalize abortion and discourage its use (Flavin, 2008; Reagan, 1997; Schoen, 2005; Solinger, 1992, 2007). Indeed, historians have documented that fears of women having rampant sex and the specific pathologizing of the reproductive bodies of marginalized women were central concerns for some antiabortion activists and legal abortion gatekeepers (Reagan, 1997; Solinger, 2007). The framing of abortion in the U.S., in other words, has been intricately linked with stories about bodies and sexuality.

In this article, we review the small body of research on abortion and sexuality in the U.S. using critical interpretive synthesis (Dixon-Woods et al., 2006), highlighting the frameworks that the authors use to understand the relationship between the two, and elaborate a conceptual framework that draws attention to the importance of the embodied sexual experience in research on abortion. Broadly, embodiment deals with “the experience of living in, perceiving, and experiencing the world from the very specific location of our bodies” (Tolman et al., 2014, p. 760). Our conceptualization of sexual embodiment emphasizes the role of sensuousness in people’s experiences as embodied individuals in society (Turner, 1984). As such, it recognizes the role of culture in classifying and regulating sexual bodies and how those processes are based on cultural meanings and people’s experiences living within their reproductive bodies. Moreover, it understands those experiences as governed by not only individuals themselves but also biology and society (Turner, 1984). After elaborating our framework, we provide examples of new research pathways offered by our conceptualization.

Background

A great deal of scholarship has studied abortion, approaching the topic from multiple disciplinary perspectives, including clinical, social scientific, and bioethical. To make sense of this literature, scholars have conducted reviews of abortion research. They have produced reviews of research on women’s abortion experiences and decision-making (Kanstrup et al., 2018; Kirkman et al., 2009; Lie et al., 2008; Purcell, 2015), abortion stigma (Hanschmidt et al., 2016), post-abortion mental health (American Psychological Association Task Force on Mental Health and Abortion, 2008; Charles et al., 2008), abortion attitudes (Jelen & Wilcox, 2003; Yam et al., 2006), and male partner involvement in abortion (Altshuler et al., 2016), as well as of clinical research on abortion and of evaluations of abortion services and access to abortion. Frequently, reviews have concluded with a call for more high-quality research in the area (e.g., Altshuler et al., 2016; Charles et al., 2008; Hanschmidt et al., 2016; Kanstrup et al., 2018; Purcell, 2015), suggesting that despite the proliferation of research on abortion, important research questions remain incompletely addressed.

We identify two additional gaps in research and reviews of research on abortion to date, and we believe they are related. The first gap we identify is the absence of a recent review of the literature on abortion and sexuality and of any review of the topic with a broad definition of sexuality. There are two reviews of work on abortion and sexuality, both on research published more than twenty years ago and both with a focus specifically on post-abortion sexuality. Bianchi-Demicheli et al. (2000) reviewed the literature on post-abortion psychosexuality, finding just four relevant papers, which were published as long ago as 1973. Across the four articles, they found that about one-quarter of couples separated after the abortion. In three of the four articles, they found that a minority of women reported sexual dysfunction following abortion. Three years after Bianchi-Demicheli et al.’s review, Bradshaw and Slade (2003) conducted a review of research published between 1990 and 2000 on (1) emotional responses to abortion, and (2) the effects of abortion on sexual relationships or sexual functioning. They found eight articles relevant to this latter interest, from which they concluded that most women report no effects of abortion on their sexual relationships, but a small subset report negative effects. They further noted that the quality of the reviewed studies was mixed and that it is difficult to tease out the effects of an unwanted pregnancy versus an abortion on relationships and sexual functioning, as all the abortions were preceded by an unwanted pregnancy.

None of the more recent reviews of abortion research has focused on scholarship on abortion and sexuality (either narrowly or broadly defined), but there are hints of the relevance of sexuality in research on abortion. For example, in three reviews of research on women’s reasons for abortion, the reviewing scholars have discussed articles that consider both abortion and sexuality. Specifically, in her review, Purcell (2015) briefly noted that Izugbara et al. (2011) found that cultural definitions of appropriate motherhood and sexuality interact with and influence women’s abortion decisions. In their review, Kirkman et al. (2009) noted that sexual assault is a reason for abortion. And, in their review, Lie et al. (2008) reported Bennett’s (2001) finding that, in Indonesia, healthcare workers’ approval for patients’ reasons for abortion was linked to their attitudes toward sex outside of marriage. All three reviews, in other words, cover articles that relate to both abortion and sexuality. As another example, a review of research on abortion attitudes found that attitudes toward abortion are associated with attitudes toward sexual morality and sex outside of marriage (Jelen & Wilcox, 2003). Sex and sexuality are also mentioned in the APA Task Force on Mental Health and Abortion’s (2008) review of research on post-abortion mental health. The review noted that the literature has found that early sexual activity is a predictor of unwanted pregnancy, which is associated with choosing abortion. Additionally, in their review of research on abortion stigma, Hanschmidt et al. (2016) defined abortion stigma as rooted in abortion’s challenge of social norms of women’s sexuality and maternity, thereby constructing sexuality as foundational to abortion stigma. Thus, these reviews point to the scholarly value of a review explicitly focused on the literature on abortion and sexuality, defined broadly.

The second gap we identify is that the reviewed research – across topics – tends to conceptualize abortion solely as a pregnancy outcome, illustrating the absence of other conceptual frameworks. We acknowledge that, of course, abortion is a pregnancy outcome. But we further stipulate that abortion is also part of a longer sequence that usually includes people’s experiences with intimate interactions, vaginal sexual intercourse, contraceptive behavior, and other experiences that occur both before and after an abortion. Research on other sexual and reproductive experiences has attended to these experiences as part of a longer sequence and not strictly as standalone events. For example, as Higgins and Smith (2016) showed in their excellent review of the sexual acceptability of contraceptives, scholarship has examined people’s experiences of the methods that they use to manage their fertility in conjunction with their experiences of pleasure and sexuality, extending consideration of contraception beyond the sex act and/or prevention of pregnancy.

We posit that conceptualizing abortion as a pregnancy outcome makes it difficult to think about sexuality and abortion as mutually interrelated and thus diverts attention from interrogation of the relationship between abortion and sexuality. The conceptual framing of abortion as a pregnancy outcome, in other words, enables some research questions and not others. To be clear, we are not suggesting that existing conceptualizations of abortion are wrong. Rather, we aim to highlight how extant frameworks both enable and constrain what knowledge is available.

Here, we offer a critical interpretive synthesis of the literature on abortion and sexuality with attention to conceptual framework(s) of abortion, sexuality, and their relationship. We use an expansive definition of sexuality as inclusive of sex, sexual expression, and sexual behavior and consider sexuality at any time, not strictly post-abortion, asking: how do relevant studies conceptualize abortion, sexuality, and their relationship? Because how abortion is conceptualized is rooted in social, cultural, and historical context, we restrict our analysis to research based in the U.S. Scholars have demonstrated that the social meaning of and ongoing political contestation over abortion are features of the U.S. political system, including its tripart government, two-party system, and logic of checks and balances (Halfmann, 2011; Schlozman, 2015), and the country’s racial history of privileging and preserving a white identity in response to the legacy of chattel slavery and ongoing anti-Black racism (Holland, 2020). In these ways, abortion in the U.S. importantly differs even from other English-speaking countries like Canada and Britain (Halfmann, 2011). Further, since the legalization of abortion nationally in 1973, the meaning of abortion has been conceptualized by advocates in multiple ways. For example, while (mostly white) pro-choice activists in the 1970s and 1980s saw access to abortion itself as liberatory (Luker, 1984), Black activists in the 1990s championed the framework of reproductive justice, conceptualizing abortion as just one part of a liberatory politics of reproduction that must always be accompanied by the right to parent and to do so in safe and sustainable communities (Ross & Solinger, 2017).

Method

We conducted a critical interpretive synthesis review (Dixon-Woods et al., 2006). This approach is appropriate for reviews like ours that are exploratory rather than hypothesis-testing and that include papers using different methods (i.e., qualitative and quantitative methods). It utilizes the comprehensive searching processes of quantitative reviews (e.g., systematic reviews) and the interpretive tradition of qualitative reviews (e.g., meta-ethnography). Critical interpretive synthesis suits our purposes by enabling interrogation of epistemological and normative assumptions of the literature itself, rather than simply the summarization of findings and/or evaluation of methodological strengths and weaknesses.

Search Strategy

We started by identifying relevant publications on both abortion and sexuality published in English. To ensure that our search captured as many relevant publications as possible, we contacted a clinical librarian with expertise in obstetrics and gynecology at the University of California, San Francisco who assisted in developing Boolean search terms and identifying target databases. Our final literature search included four primary databases – PubMed, Sociological Abstracts, Social Services Abstracts, and PsychINFO – and one supplemental database, Google Scholar. We began by searching the four primary databases to compile a list of relevant texts, which we imported into a reference manager. The primary databases generated 127 non-duplicate titles. We then searched Google Scholar as a supplemental database (Giustini & Boulos, 2013; Haddaway et al., 2015), which yielded over 300,000 results. Because there are no current standards around how many Google Scholar results to include and our purpose was to analyze the literature on a focused topic, we imported the first 100 results and scanned an additional 25 results to ensure that we did not omit relevant references. After removing 18 duplicates generated from the Google Scholar search, our initial sample for review included 209 references. Searches were run in April and May 2020. Table 1 displays the search strategies used for each database.

Table 1. Databases and search terms

Database	Search Terms	Results
PubMed	(“sexual pleasure”[ti] OR “sexual behavior”[ti] OR “sexual behaviors”[ti] OR “sexual preference”[ti] OR “sexual preferences”[ti] OR “sexual acceptability”[ti] OR “sexual practice”[ti] OR “sexual practices”[ti] OR sexuality[ti] OR “sexual activity”[ti]) AND (abortion[ti] OR abortions[ti] OR “pregnancy termination”[tiab] OR “termination of pregnancy”[tiab])	41
Sociological Abstracts/Social Services Abstracts	ti(abortion OR abortions) AND ti(sexuality OR sexual)	61
PsycINFO	(abortion OR abortions) AND (sexuality OR sexual)	43
Google Scholar	Abortion AND (sexuality OR “sexual behavior” OR pleasure)	300k+

To identify articles for inclusion, we began by reviewing the title and abstract for each citation on the list. We excluded items that examined animals, book reviews, studies based in non-U.S. contexts, and studies that were not about both abortion and sexuality. In most cases, the focus of the study could be determined using the title and the abstract. When in doubt, the second author reviewed the full text of the article to make determinations regarding inclusion. To determine whether a book on the preliminary list should be included in the final sample, we reviewed the book’s title, description, table of contents, and index for the same criteria applied to articles. Consistent with critical interpretive synthesis review practices, we did not exclude items based on method used.

Ten texts met our search parameters after initial review and both authors reviewed them in-depth. Three of the 10 were excluded at this stage: two articles mentioned sexuality in the title but did not examine abortion and sexuality in the body of the article; the third was a systematic review of studies on abortion and sexuality that included only studies based in Europe (Bianchi-Demicheli et al., 2000, discussed above). This left us with seven sources that explicitly dealt with abortion and sexuality in the U.S. context – six articles and a book.

Coding Strategy & Analysis

Based on our training as sociologists and our deployment of a feminist epistemology that recognizes the lenses that different life experiences bring to the research process, our critical interpretive synthesis utilized an inductive qualitative methodology that honored the perceptions of both authors. We treated each publication as a text, in the parlance of qualitative analysis, examining them for their conceptualization(s) of abortion, sexuality, and the relationship between the two. For the book, the first author developed a list of potentially relevant pages by using both the table of contents and the index, drawing on her familiarity with the book from having read it previously. This yielded 56 pages of potential relevance. The first author reviewed these pages and determined that only 25 were relevant to this analysis.

Both authors independently reviewed the seven texts to inductively develop a set of codes to capture the major themes related to conceptualization of abortion and sexuality. Our major codes included: abortion as a social problem, abortion as an independent or dependent variable, sexual behavior as an independent or dependent variable, and irresponsible sex. We each then applied the codes independently of each other in the qualitative analytic software Dedoose, coding “blind” to the other’s work. During the coding process, the first author wrote memos summarizing patterns across texts.

To assist in the synthesis of frames across sources, we created dichotomous “yes/no” variables based on each code using Dedoose’s “Descriptors” feature. After first qualitatively coding each text to identify portions of the material in evidence of the theme, we assigned a dichotomous value to each source for each code so that we could quickly identify the frames engaged with at the source-level. Because this could not be accomplished “blind,” the first author assigned values for each source upon completing its coding. The second author then reviewed and confirmed the values assigned for each source, identifying no discrepancies.

Both authors then discussed the codes, descriptors, and memos, identifying salient conceptualizations of abortion, sexuality, and their relationship in the texts. This was an iterative conversation, involving returning to the texts, codes, descriptors, and memos multiple times to identify overarching frameworks. We identified two conceptual frameworks in operation. The first author then reviewed each text’s codes and memos and categorized the conceptual framework of the text. The second author reviewed and confirmed these categorizations. We had no disagreements on these categorizations.

Supplemental Analysis

After our analysis of U.S.-based texts, we conducted a secondary search of the literature in order to perform a general check on our assumption that U.S.-based projects may rely on context-specific, non-universal conceptualizations of abortion. We started from the same initial list of database results and utilized the same initial exclusion criteria, except we excluded publications that drew only on U.S.-based data and texts published before 2000. The latter exclusion criterion helped keep the sample manageable while retaining what we considered to be recent conceptualizations (i.e., in the last two decades). We found seventeen relevant articles.

Because it was outside of the scope of our interpretive synthesis, we did not formally code these articles. Both developing a framework and articulating the cross-national contours of abortion discourses would have been unwieldy for a single review. We did, however, fully review the articles for confirmation of the specificity of the U.S. context for conceptual frameworks as well as for alternative conceptualizations of the relationship between abortion and sexuality.

Extant Conceptual Frameworks

The included studies on abortion and sexuality in the U.S. context were published in health research journals, law journals, psychiatry journals, and book form. They were authored by legal scholars, sociologists, and psychologists. In other words, the texts were not confined to a particular disciplinary area or approach. Below, we detail the two major frameworks underlying scholars’ examination of abortion and sexuality our synthesis revealed: treating abortion and sexuality as causally related and treating abortion as a social problem that is related to irresponsible sex in the public imagination. As with most of the studies in the reviews of abortion research discussed above, across all seven texts and in both conceptual frameworks, abortion was conceptualized as a standalone event.

Causally Related and Distinct: Abortion and Sexuality at the Individual Level

Two articles in our sample examined abortion and sexuality as characteristics of individuals, utilizing a framework that constructed abortion and sexuality – operationalized as sexual behavior – as distinguishable entities that could be defined and measured independently of one another. They further constructed these entities as causally related.

Sociologists Rosen and Martindale (1980) conceptualized attitudes toward sexual behavior as a component of people’s overall position on women’s role in society. And they hypothesized that having a greater feminist orientation – inclusive of a perception of a sexually legitimate self – was associated with choosing abortion for an unexpected pregnancy, positing a causal relationship between sexuality and abortion. Human development professor Coleman et al. (2008) likewise constructed abortion and sexual behavior as causally-related variables, but they conceptualized a different directionality to the relationship. They posited that experience of abortion, both one’s own or a partner’s, may lead to particular attitudes and patterns of behavior.

Both sets of authors found support for their hypotheses. Using survey data collected from 1,598 women in Michigan from 1974 to 1975 who had experienced an unplanned pregnancy, Rosen and Martindale found that women choosing an abortion scored lower on a scale measuring traditional attitudes about women’s roles than did women who carried the pregnancy to term. The authors concluded from these results that having a less traditional understanding of women’s role, including being comfortable with women as sexual beings, leads women to feel more comfortable choosing abortion. Coleman et al., meanwhile, examined the effect of a history of abortion on sexual behavior and attitudes using data from 1,963 women and men between ages 18 and 59 who completed questions about their history of abortion as part of the National Health and Social Life Survey in 1992. The authors reported support for their hypothesis and concluded that abortion causes these specific outcomes (e.g., positive attitudes about casual sex and casual sexual behavior). While the authors discussed “associations” between the variables and noted that the study must be “exploratory,” they also used causal language and stated that their results “are suggestive of a causal connection” (p. 88).

We do not adjudicate these potentially contradictory findings here, focusing instead on the similarities in both articles’ conceptualization of abortion and sexuality as distinct and causally related. Although they focused on research outside of the U.S., Bianchi-Demicheli et al.’s (2000) and Bradshaw and Slade’s (2003) reviews covered research engaged in similar questions about the effects of abortion on subsequent sexuality, suggesting that this conceptual framework extends beyond the U.S. context.

Explaining Ideological Positions on Abortion: Abortion and Sexuality as Social Problems

The remaining texts in our sample examined abortion and sexuality at the level of the social, rather than the individual, while still conceptualizing abortion as a standalone event. All five engaged with abortion and sexuality to unpack how opposition to abortion is constructed in political, legal, and/or social discourses, arguing that the construction of some sex as inappropriate is an ideological origin of opposition to abortion. Across these texts, in other words, scholars framed hostility to particular expressions of sexuality as the underpinnings of opposition to abortion in the U.S. Some texts also engaged with how affirmative beliefs about sexual liberation and the right to sexual pleasure undergird ideological support for abortion rights.

Three texts conceptualized hostility to specific expressions of sexuality as informing ideological opposition to abortion. Sociologists Di Mauro and Joffe (2007) argued that leaders of the religious right in the U.S. from the 1970s to the 2000s constructed the liberalization of abortion law and comprehensive sexuality education as threats. What was threatened, Di Mauro and Joffe argued, was sexual conservatism, premised on a denial of “the pursuit of sexual pleasure as an inalienable right” (p. 70). They argued, in effect, that sexual conservatism underlies opposition to abortion and efforts to restrict abortion access, conceptualizing abortion and sexuality as social problems related by way of ideological discourse.

Legal scholar Siegel (2012) deployed a similar conceptualization of the relationship between sexuality and abortion. Siegel argued that antiabortion dignity claims in legal settings, which have been interpreted by courts as applying to the dignity of potential life, also concern sex and are rooted in a religious ideology that restricts sexuality to intra-marital, procreative sexual activities. Siegel thus conceptualized abortion and sexuality as interlinked social problems with opposition to abortion inextricably tied to beliefs about appropriate sexual expression and gender-specific expectations for women’s sexuality.

Psychologists Katz and Tirone (2015) drew a similar connection between sexuality and abortion, conceptualizing them as social problems that are linked in the public imagination. They differed, however, in sourcing this connection in the contemporary dominance of neoliberalism. They argued that opposition to abortion is connected to neoliberal judgments of women’s “sexual (mis)behavior” (p. 316) in “not having better control over their fertility” (p. 314) – that is, becoming pregnant when they do not wish to be – and the construction of sexual pleasure primarily in male-centered ways. Katz and Tirone asserted that these judgments support both framing abortion strictly in terms of the fetus and ignoring the rights of the pregnant person, thereby contributing to laws that, among other things, enable people like parents and lawyers to exert control over people’s sexual behavior.

The remaining two texts conceptualized beliefs about sexuality as informing not only ideological opposition to abortion but also support for abortion rights. Sociologist Petchesky (1984) identified beliefs about women’s sexuality as central to what she termed “antifeminists’ ideological position” on abortion. Noting that sexuality and abortion have no intrinsic meaning, she argued that, for opponents of abortion in the late twentieth century, abortion came to represent inappropriate sexuality – a category which included extramarital sexual behavior, sexual behavior among teenagers, and sexual behavior without intent to procreate. For supporters of abortion rights, in contrast, abortion served as a symbol of an experience that enables sexual liberation for women. Petchesky’s conceptualization of abortion and sexuality, then, linked the two by way of ideological discourse, presenting the symbolic meaning of abortion as a signifier of (in)appropriate sexuality that motivates ideological position on abortion access.

In her law journal article, legal scholar Morvai (1994) similarly conceptualized abortion and sexuality as related by way of discursive logics both for and against abortion rights. Like Petchesky, Morvai conceptualized the relationship between sexuality and abortion as explaining the construction of abortion as a social problem. Among opponents of abortion, she asserted, abortion is problematic because it represents non-reproductive sexuality, including sexuality for the purposes of pleasure. Supporters of abortion rights, in contrast, subscribe to the belief that access to abortion represents the possibility of sexual liberation.

The Limits of Existing Frameworks

Our analysis reveals that despite a small body of informative research on the topic of abortion and sexuality in the U.S. context, there is room for much more research as well as an opportunity to add to our conceptual toolkit as abortion and sexuality researchers. Our review of English language articles on non-U.S. data for confirmation of our decision to limit our focus to U.S.-based research found, surprisingly, that these additional seventeen articles conceptualized abortion, sexuality, and their relationship in ways that were broadly consistent with the U.S.-based studies. Scholarship investigating the relationship between abortion and sexuality outside of the U.S. context also relies on a conceptualization of abortion and sexuality as distinct and causally-related (e.g., Bianchi-Demicheli, Perrin, Lüdicke, Bianchi et al., 2001; Bianchi-Demicheli, Perrin, Ludicke, & Campana, 2001; Boesen et al., 2004; Fok et al., 2006) or of abortion as a social problem, with its frequency related to irresponsible sex (e.g., Ekstrand et al., 2005; Klingberg-Allvin et al., 2006, 2007; Obiyan & Agunbiade, 2014).

While these frameworks provide important grounding for research studies, there are also limits to the research questions and kinds of knowledge that the frameworks can generate. For the first framework we identified in the existing literature, constructing abortion and sexuality as causally related directs researcher attention away from the simultaneity of abortion and sexuality and, thus, research questions founded in this observation. Abortion may inform changes in sexuality just as sexuality may shape the embodied experience of abortion and abortion decision-making. One non-U.S.-based study drew on a conceptualization that gets closer to this idea. To investigate post-abortion experiences of sexual satisfaction, Bradshaw and Slade (2005) utilized the Sexual Behavior Sequence model (Byrne & Byrne, 1977) to posit that abortion, as an outcome of sexual behavior, may affect subsequent sexual behavior and attitudes, especially if the outcome (i.e., the abortion) is evaluated by the woman as positive or negative. A person’s sexuality, then, is an ongoing production, with experiences such as abortion – which the authors suggest could be viewed as a negative sexual outcome because of its social meaning – potentially causing changes in behavior and attitudes. Still, Bradshaw and Slade’s (2005) conceptualization retains the construction of abortion and sexuality as distinct, causally related variables. As such, it is constrained in what research questions it can explore.

Scholarship on abortion and sexuality premised in a larger social narrative that treats abortion as a social problem creates similar challenges for generating knowledge on the interplay between abortion, sexuality, and social processes related to both. In particular, it can lead researchers to overlook the possibility that a third “variable” influences both abortion and sexuality. When researchers focus on examining the relationship between abortion and sexuality and draw on their own socialized understanding that abortion is a social problem, they may be unable to identify the institutions, practices, and social arrangements that may be in fact influencing both abortion and sexuality. Put differently, in relying on a conceptualization of abortion as a social problem, there is little room for researchers to interrogate the sense-making processes that are fundamental to producing models of the social world, including of what constitutes a social problem. Instead, abortion is stipulated to be a social problem and scholars seek the reasons for its production as such, commonly identifying other sex- or gender-related social issues as potential analogies or explanations. The consistency across the texts deploying this second frame points to a hegemony of theorizing, which makes it difficult to recognize other relevant influences on observable outcomes and may reduce the generation of additional research questions and knowledge on the topic.

Jointly, these frameworks are not quite in step with other scholarship on sexuality and reproduction, some of which has begun to focus on the body (e.g., Bowleg et al., 2017), pleasure (e.g., Higgins & Smith, 2016), and the life course (e.g., Carpenter & DeLamater, 2012). Neither of these frameworks used to analyze abortion and sexuality easily links into frameworks deployed in recent scholarship on related areas.

Sexual Embodiment: An Alternative Lens

The conceptual frameworks used by these texts, as would any conceptual framework, impose constraints on the kinds of research questions asked and, consequently, on the kinds of knowledge produced. As we noted at the outset, we are not asserting that existing conceptualizations are wrong. Rather, we seek to draw attention to how a multiplicity of conceptual frameworks can enable new research questions and new knowledge. Our critical interpretive synthesis of extant literature on the relationship between abortion and sexuality reveals that there are notably few current conceptual frameworks operating in this area. We offer an additional conceptual framework that re-envisions the relationship between abortion and sexuality by rooting abortion in an embodied social experience. As we show, this lens offers a pathway for exploring a host of unexplored research questions and addressing some of the limitations of current approaches. We offer the framework in the spirit of opening up new conceptual space for investigation.

Integrating Sexual Embodiment into Abortion Research

We propose a conceptual framework for examining abortion and sexuality that highlights the importance of the embodied experience. Following in this tradition, we highlight sexual embodiment as the “lived experience of the sensual or subjective body,” noting especially that the body and the self are co-constructive (Turner, 2008, p. 245). That is, the body cannot exist outside of the self and the self is informed by people’s experiences within their bodies. This means that researchers cannot disentangle abortion as a reproductive process from broader corporeal (and carnal) experiences of sexuality because they mutually inform each other. We argue that utilizing a framework that recognizes abortion as an embodied experience that is part of broader sexual social processes can enable new research questions and valuable new knowledge. (We acknowledge that researchers have attended to the embodiment of abortion, e.g., Broussard, 2020; Love, 2021; Purcell et al., 2017; D. P. Siegel, 2020; our focus here is specifically on sexual embodiment.) To start, we note that the encounters that generate the opportunity for abortion almost always involve embodied experiences of sexual intercourse, even if those experiences drop out of focus in the process of developing research questions and reporting results. And the body itself is intersectional, grounded in multiple dynamic individual, interactional, and social identities. Its meaning is also produced by multiple dynamic structures, including structures of oppression. The body is the thread that undergirds reproductive social processes, including abortion. Integrating sexual embodiment, then, highlights for the researcher that abortion and sexuality are simultaneous and inherently integrated in a broader social fabric. Maintaining recognition of how abortion and sexuality are interrelated and embedded in other social processes supports the development of nuanced and appropriately complex conceptual models.

This conceptual approach underscores the importance of attending to sexuality in terms of how people experience abortion as embodied sexual beings. This approach recognizes that people both have bodies and are bodies. As such, their experiences of abortion and sexuality are shaped by 1) larger social structures of power that act on and through their bodies based on social location, 2) the cultural contexts that shape the meanings that they attach to sex, pregnancy, and abortion, and 3) their own feelings, perceptions, sensations, and choices as embodied people with personal histories. There are longstanding debates on the appropriate way to conceive of the body (e.g., as existing prior to culture or only coming into being through the enactment of cultural meaning) (Balsamo, 1996; Butler, 1990, 1993; Turner, 1984). Conceiving of an embodied experience in the way that we suggest offers a conceptual middle ground. Specifically, it grapples with the intersection of the biological and social in abortion and sexuality, thereby building a richer picture of people’s lived experiences managing fertility than that rendered by attending only to the biological or the social.

Focusing on sexual embodiment enables research questions about power and how inequality operates on and through bodies. What if the relationship between abortion and sexuality is not (only) sex and gender related? White supremacy, for example, could undergird both opposition to abortion (Holland, 2020) and the regulation of particular sexual behaviors (Ferguson, 2004). Given that, in the U.S., the rate of ever having vaginal sex (Chandra et al., 2013), number of lifetime sexual partners (Chandra et al., 2013), and frequency of sex (Twenge et al., 2017) are associated with race, understanding the relationship between abortion and sexuality at the level of social, political, and legal discourse may require attention to race. Conceptualizing people as embodied sexual beings brings attention to not only gender but also other axes of oppression.

Attending to the interplay between abortion and sexuality that highlighting sexual embodiment compels can direct researchers to new questions, for example, following the lead of other researchers in related areas. Increasing awareness of the prevalence of sexual assault and intimate partner violence in patient populations has led to scholarly and clinical interest in trauma-informed care practices. Trauma-informed care is an evidence-based approach that recognizes the prevalence of trauma in patients’ (and healthcare professionals’) lives and seeks practices of care provision that avoid re-traumatization and promote healing and recovery. In the realm of obstetrics, midwifery, and gynecology, scholarship has researched the integration of trauma-informed care in prenatal care and childbirth as well as in gynecologic care unrelated to pregnancy (Reeves, 2015). Trauma-informed abortion care has not received the same attention in the literature. Such questions are difficult to engage under a framework that conceptualizes abortion and sexuality as fully separable. Sensitivity to how the body links abortion, sexuality, and power enables research questions about how sexual experiences, including non-consensual experiences, prior to an abortion may matter for how the abortion is experienced, as well as questions about how and what aspects of the delivery of abortion care may matter for subsequent sexual experiences.

Integrating sexual embodiment also enables recognition that pregnancy decision-making may precede conception. For example, women who have pregnancy “scares” after having vaginal intercourse without contraception (Gatny et al., 2014) may consider abortion long before they actually experience a pregnancy. Research shows that women who experience a pregnancy scare stop using contraception or continue to use it inconsistently, among other behaviors that researchers believe increase women’s chances of conceiving (Gatny et al., 2018). While Gatny et al. (2018) suggested that this behavior might be related to an increased desire for pregnancy following a scare or to an increase in fatalistic beliefs about pregnancy, we suggest that it is also likely related to sexual embodiment. Individuals may not know how they will resolve a potential unexpected pregnancy but may decide to stop using contraception or use it inconsistently because, for instance, they assume they are already pregnant and enjoy sex without contraception. After all, we know from a plethora of studies that pleasure and satisfaction matter for people’s use of contraception (Fennell, 2014; Higgins & Hirsch, 2007, 2008; Higgins et al., 2008; Higgins & Smith, 2016). Those managing contraception following a pregnancy scare, then, must simultaneously contend with how contraception affects pleasure and their experiences of their bodies, how they experience a potentially pregnant body, and how they anticipate they might resolve an unexpected pregnancy. Treating abortion as an embodied sexual experience, then, makes it possible to recognize the complexity of the timing of abortion consideration. It paves the way for researchers to explore new areas: How does experience of a pregnancy scare, for example, shape attitudes about abortion? How does having a pregnancy scare shape pleasure in the period immediately following, before (non-)pregnancy is confirmed? And, does previous experience with a pregnancy scare differentiate decisional certainty regarding both birth and abortion when a person actually conceives?

The utility of attention to sexual embodiment can offer insights into demographic patterns as well. For example, scholars have noted the downward trend in the abortion rate in recent years (Jones & Jerman, 2014; Jones et al., 2019), prompting a series of scholarly debates about its cause. To explain this trend, some have pointed to increased use of more effective contraceptive methods (Jones & Jerman, 2017; Jones et al., 2019), while others have disputed this as a comprehensive explanation for the trend (Foster, 2017). Still others have shown that increasing state-level restriction of abortion contributes to pregnant people being unable to obtain abortion care (Upadhyay et al., 2014), which may explain this decrease. Our framework prompts us to ask: how might people’s sexual behavior and, specifically, decreases in sexual activity in the last decade (Twenge, 2020; Ueda et al., 2020) affect the abortion rate?

As the aforementioned questions suggest, contextualizing abortion as part of a sexual social process is not incongruent with causal logic. Causal logic is crucial for understanding the social factors that affect abortion and the effects of policy on abortion accessibility, among other things. Researchers studying abortion and sexuality under causal logic, however, must be particularly mindful of the body in tethering abortion to sexuality to avoid challenges when making assumptions about causality in the absence of appropriate, longitudinal data to support such claims. One option would be to deploy mixed-methods research to uncover the mechanisms undergirding any differences observed in quantitative results rather than relying on theories that presume causality. Researchers could also ask how experiences of and attitudes about abortion and sexuality interrelate with how people have sex. Is previous experience with abortion and carrying a pregnancy to term related to subsequent experiences engaging in particular kinds of sexual interaction (e.g., contraceptive [non-]use, non-penetrative sex)?

Using the lens we introduce here also reveals the need to develop the kind of conceptual clarity that is foundational for any subfield. While abortion is a pregnancy outcome that is usually preceded by sexual interaction(s), our conceptual review reveals that scholars rarely grapple with sexual desire and motivation when investigating abortion. Thus, even a basic question has not yet been answered by the literature: how should pleasure and satisfaction be measured in this context? The conception of pleasure that dominates the broader literature – tactile perceptions during acts of sexual intimacy – misses the opportunity to elucidate other dimensions of pleasure that may characterize experiences of abortion and sexuality (e.g., the pleasure that comes from accomplishing one’s goals, from feeling supported, and/or from relief at ending an unwanted pregnancy). Researchers might examine whether people who can become pregnant perceive sex as more pleasurable when they have ready access to abortion care or medications to self-manage an abortion (because knowing that they can, for example, might reduce fear that their rightful pregnancy options will be limited in the event of conception).

Related to this line of inquiry, researchers have shown that, for some people who carry their pregnancies to term, sexual desire and satisfaction decrease with pregnancy (Pauleta et al., 2010). What might desire, sexual frequency, and satisfaction look like in a population of pregnant people ambivalent about or not planning to carry their pregnancies to term? How might delays in obtaining abortion care affect sexual desire, frequency, and satisfaction? Researchers have documented sources of delay in getting a clinic-based abortion, examining whether abortion waiting periods (Roberts et al., 2016), difficulty accumulating resources to cover the cost of an abortion (Cook et al., 1999; Roberts et al., 2019), and distance to a provider (Fuentes & Jerman, 2019; Grossman et al., 2017) affect if and how quickly someone has an abortion. Our framework points to questions about how these common experiences of seeking abortion care might shape sexual experiences both during the delay period and afterward. This research could lead to the development of conceptual models of pleasure that can improve understandings of pregnancy decision-making and inform care delivery, as well as potentially articulate additional consequences of policies restricting abortion. Future research would also benefit from elaborating the dimensions other than pleasure that comprise people’s experiences with sexual embodiment as it relates to abortion.

Discussion and Conclusion

The literature on abortion and sexuality in the U.S. is small – and not much larger when English-language studies based outside the U.S. are included. This is surprising given the interrelatedness of these experiences: abortion is nearly always preceded by sex and, as we argue above, must be understood in this social context. We posit that the small size of this subfield can be partially explained by the conceptual frameworks that characterize current research. Our critical interpretive synthesis revealed that the seven U.S.-based texts that jointly engaged with abortion and sexuality either constructed the two phenomena as distinct, causally-related variables (when examined at the individual level) or conceptualized beliefs about (in)appropriate sexuality as undergirding and explaining social, political, and legal positions on abortion (when examined at the discourse level). Our review of non-U.S.-based English language studies found that these frameworks were present in studies conducted in other settings as well.

Obviously, it is impossible for seven texts to fully conceptualize the relationship between abortion and sexuality. Along with calling for more research on abortion and sexuality, we offer an additional conceptual framework in the spirit of inspiring new research. The existing frames present challenges for investigating abortion as a component of people’s sexual lives and for connecting research on abortion to other literature on sexual and reproductive experiences that centers intersectional embodiment (e.g., Bowleg et al., 2017; Carpenter & DeLamater, 2012; Higgins & Smith, 2016). We suggest that a conceptual framework that integrates sexual embodiment in research on abortion can bridge the literatures on abortion and other aspects of reproduction, enabling new research questions, insights, and theoretical innovations.

As our formal analysis is limited to scholarship in the U.S., the lack of attention to sexual embodiment may reflect culturally-specific understandings of both abortion and sexuality in this context. However, our review for framework applicability in non-U.S.-based English language studies found the two conceptualizations we identified were broadly applicable. Given variation in how abortion is understood socially and politically in different political systems (Halfmann, 2011), we suggest that it is odd that we would find uniformity or at least resonance in conceptualizations across the research literature. Future scholarship should examine the frames deployed across contexts to understand how scholars grapple with particular cultural ideologies at the abortion-sexuality nexus.

To close, we enthusiastically call for both more research on abortion and sexuality and more research in this subfield that highlights sexual embodiment. Attending to embodied experiences of sexuality in abortion can inform care delivery and policy, offer insight into pregnancy decision-making and negotiations about sexual experiences, and improve people’s reproductive autonomy and well-being. We hope that the conceptual framework that we put forth proves generative for emerging and experienced scholars alike.

Acknowledgments

The authors thank Jill Barr-Walker for her assistance in developing the study design.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the David and Lucile Packard Foundation (2020-70623) and an anonymous foundation.