| 1) Please enter your current age. |
| 2)What is your race/ethnic origin? |
Caucasian
African American
Hispanic
American Indian
Asian
Other
|
| 3) What is your country of citizenship? |
| 4) What is your highest level of education? |
less than 12 years
high school diploma
technical training or associate degree
bachelor's degree
graduate degree
|
5) What is your employment status? |
Full-Time
Part-Time
Unemployed
|
| 6) Please indicate your current marital status. |
married
remarried
single (never married)
single (divorced)
single (widowed)
separated
|
| 7) If you have living children, please indicate how many. |
| 8) If you have experienced more than one abortion, please indicate how many. |
| PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR ABORTION EXPERIENCE. IF YOU HAVE EXPERIENCED MORE THAN ONE ABORTION, PLEASE CONSIDER THE ONE MOST STRESSFUL TO YOU AS YOU ANSWER THESE QUESTIONS. |
| 9a) How long ago did the abortion occur? years months |
| 9b) How many weeks pregnant was your partner at the time of the abortion? weeks
|
| 9c) If you know what type of abortion was performed, identify it from the following list: |
Suction aspiration
D & C (dilation & curettage)
D & E (dilation & evacuation)
Saline induced abortion
Prostaglandin abortion
Hysterotomy
Intact dilation & extraction (partial-birth abortion)
Chemically induced abortion (RU 486)
|
| 10) Were you married to your partner at the time of the abortion? |
Yes
No
|
| 11) Were you using contraception at the time the pregnancy occurred? |
Yes
No
|
| 12) Was that pregnancy desired by you? |
Yes
No
|
| 13) Was that pregnancy desired by your partner? |
Yes
No
|
| 14) After scheduling your abortion, do you think a required waiting period would have been helpful for your decision making? |
Yes |
No |
| 15) Do you think the counseling you received at the abortion clinic was adequate? |
Yes |
No |
| 16) Do you think the abortion clinic provided you with sufficient information regarding alternatives to abortion? |
Yes |
No |
| 17) Do you think the abortion clinic provided adequate information beforehand about the physical and emotional risks of abortion? |
Yes |
No |
| 18) When the abortion decision was made |
| 18a. My partner and I both supported the decision |
Yes
No
|
| 18b. I pressured my partner into choosing abortion |
Yes
No
|
| 18c. Someone else pressured her into choosing abortion |
Yes
No
|
| 18d. I left my partner before the decision to abort was made |
Yes
No
|
| 18e. My partner chose to have an abortion against my wishes |
Yes
No
|
| 18f. I left the decision to my partner |
Yes
No
|
| 18g. I did not know about the abortion until after it occurred |
Yes
No
|
| 19) Please indicate if any of the following were reasons that influenced your or your partner's decision to abort. Choose all that apply. |
| 19a. Mental Health / Emotional distress |
Yes |
No |
| 19b. Physical Health |
Yes |
No |
| 19c. Financial Concerns |
Yes |
No |
| 19d. School / Educational Plans |
Yes |
No |
| 19e. Career Plans |
Yes |
No |
| 19f. Family Size |
Yes |
No |
| g. Social Reasons (e.g. embarrassment) |
Yes |
No |
| 20) Has your relationship continued with the same partner you had at the time of abortion? |
Yes
No
|
| 21) Has your relationship with your partner changed since the abortion? |
Yes |
No |
| 22) If you are still in a relationship with the same partner you had at the time of the abortion, how has it changed? |
| It has become |
much better than before |
| It has become |
slightly better than before |
| It is |
the same as before |
| It has become |
slightly worse than before |
| It has become |
much worse than before |
| 23) If you are no longer in the relationship, how soon after the abortion did it end? years months |
| 24) Prior to the abortion, have you ever |
| 24a: had mental health counseling? |
Yes
No
|
| 24b: been hospitalized for emotional reasons? |
Yes
No
|
| 24c: been told you needed counseling? |
Yes
No
|
| 24d: felt you needed mental health counseling but didn't go? |
Yes
No
|
| THE FOLLOWING IS A LIST OF PROBLEMS THAT PEOPLE SOMETIMES HAVE IN RESPONSE TO STRESSFUL EXPERIENCES. PLEASE READ EACH ONE CAREFULLY AND CHOOSE THE ANSWER THAT BEST DESCRIBES HOW MUCH YOU HAVE BEEN BOTHERED BY THAT PROBLEM AS A RESULT OF THE ABORTION. IF YOU HAVE EXPERIENCED MORE THAN ONE ABORTION, PLEASE CONSIDER THE ONE MOST STRESSFUL TO YOU AS YOU ANSWER THESE QUESTIONS. |
| 25) Repeated disturbing memories, thoughts, or images of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 26) Repeated disturbing dreams of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 27) Suddenly acting or feeling as if the abortion were happening again (as if you were reliving it)? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 28) Feeling very upset when something reminded you of the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 29) Having physical reactions (e.g.heart pounding, trouble breathing, sweating)when something reminded you of the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 30) Avoiding thinking about or talking about the abortion experience or avoiding having feelings related to it? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 31) Avoiding activities or situations because they reminded you of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 32) Trouble remembering important parts of the abortion experience? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 33) Loss of interest in activities you used to enjoy? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 34) Feeling distant or cut off from people since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 35) Feeling emotionally numb or being unable to have loving feelings for those close to you since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 36) Feeling as if your future will somehow be cut short since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 37) Trouble falling or staying asleep since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 38) Feeling irritable or having angry outbursts since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 39) Having difficulty concentrating since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 40) Being "super-alert" or watchful or on guard since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| 41) Feeling jumpy or easily startled since the abortion? |
Not at all
A little bit
Moderately
Quite a bit
Extremely
|
| CURRENT RESEARCH SUGGESTS THAT MEN MAY EXPERIENCE A RANGE OF REACTIONS AFTER ABORTION. PLEASE INDICATE IF YOU HAVE PREVIOUSLY EXPERIENCED ("PAST") AND/OR IF YOU ARE CURRENTLY EXPERIENCING ("PRESENT") ANY OF THE FOLLOWING AS A RESULT OF THE ABORTION. YOU MAY CHECK BOTH "PAST" AND "PRESENT" IF APPLICABLE. |
| 42a: Anger |
Past
Present
|
| 42b: Helplessness |
Past
Present
|
| 42c: Grief or Sadness |
Past
Present
|
| 42d: Guilt |
Past
Present
|
| 42e: Relationship Problems |
Past
Present
|
| 42f: Sexual Problems |
Past
Present
|
| 42g: Isolation (either feeling alone or deliberately choosing to aovid other people) |
Past
Present
|
| 42h: Difficulty Concentrating |
Past
Present
|
| 42i: Anxiety or Excessive Worrying |
Past
Present
|
| 42j: Persistent thoughts about the baby |
Past
Present
|
| 42k: Confusion about a man's role in society |
Past
Present
|
| 42l: Sadness at certain times of year (e.g. the month the abortion occurred or the month when the baby would have been born) |
Past
Present
|
| 42m: Difficulty sleeping |
Past
Present
|
| 42n: Disturbing Dreams or Nightmares |
Past
Present
|
| 42o: Alcohol and/or Drug Abuse |
Past
Present
|
| 42p: Increased Risk-Taking Behaviors (e.g. driving recklessly) |
Past
Present
|
| 42q: Felt Relieved |
Past
Present
|
| 42r: Felt more in control of my life |
Past
Present
|
| 42s: Felt more able to pursue my goals |
Past
Present
|
| 42t: Felt a sense of peace |
Past
Present
|
| 42u: Felt that I had regained my freedom |
Past
Present
|
| 43) Have you spoken about your abortion experience with any of the following? |
| 43a: Friend |
Yes
No
|
| 43b: Parent |
Yes
No
|
| 43c: Sibling (brother or sister) |
Yes
No
|
| 43d: Clergyperson (priest, pastor, or rabbi) |
Yes
No
|
| 43e: Counselor (professional or volunteer) |
Yes
No
|
| 43f: Other |
Yes
No
|
| If you have spoken to anyone, what made that discussion a positive experience for you? |
| |
| If you have spoken to anyone, what made that discussion a negative experience for you? |
| |
| 44) If you could go back to the time that the decision to abort was made, would you make the same decision? |
Yes
No
|
| 45) If you faced another unplanned pregnancy in the future, would you choose abortion? |
Yes
No
|
| 46) Which of the following most closely describes your current position regarding abortion? |
abortion should be legal for any reason at any time during pregnancy
abortion should be legal for any reason during the first trimester of pregnancy
abortion should be legal only in cases of rape, incest, serious genetic disorders, & when the mother's physical life is threatened
abortion should be legal only in cases of rape, incest, and when the mother's physical life is threatened
abortion should be legal only when the mother's physical life is threatened
abortion should never be legal
|
| 47) If your view of abortion has changed due to your personal experience, please indicate which of the following most closely describes your past position regarding abortion. |
abortion should be legal for any reason at any time during pregnancy
abortion should be legal for any reason during the first trimester of pregnancy
abortion should be legal only in cases of rape, incest, serious genetic disorders, & when the mother's physical life is threatened
abortion should be legal only in cases of rape, incest, and when the mother's physical life is threatened
abortion should be legal only when the mother's physical life is threatened
abortion should never be legal
|
| 48) Please indicate your religion. |
Christian
Jewish
Islam
Other
None
|
| 49) On a scale of one to five, how meaningful is your religion to you? |
1-Not at all Important
2
3-Somewhat Important
4
5-Very Important
|
| 50) To what degree have you forgiven the person, other than yourself, whom you most blame for the abortion? |
1-not at all
2
3-in progress
4
5-completely
NA-does not apply to my situation
|
| 51) If you blame yourself even partially for the abortion, to what degree have you forgiven yourself? |
1-not at all
2
3-in progress
4
5-completely
NA-does not apply to my situation
|
| AS YOU ANSWER QUESTIONS 52-63 BELOW, PLEASE READ EACH ONE CAREFULLY AND CHOOSE THE RESPONSE THAT BEST DESCRIBES HOW YOU FEEL TODAY AFTER HAVING EXPERIENCED AN ABORTION. |
| 52) I am a person of worth |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 53) I sometimes think I am "no good" at all |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 54) I am as capable as others |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 55) I am inclined to feel that I am a failure |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 56) I feel that I don't have much to be proud of |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 57) I have a number of good qualities |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 58) I seldom feel down or depressed |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 59) I often feel sad or unhappy |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 60) I frequently get anxious or worry about things |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 61) I tend to feel calm or at peace most of the time |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 62) I often get angry or irritable for no apparent reason |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 63) I feel hopeful about the future |
Strongly Agree
Agree
Disagree
Strongly Disagree
|
| 64) Have you ever suffered any of the following? |
| 64a: Child Abuse |
Yes
No
|
| 64b: Child Nelgect |
Yes
No
|
| 64c: Sexual Abuse during childhood or adolescence |
Yes
No
|
| 64d: Physical Abuse during adulthood |
Yes
No
|
| 64e: Sexual Abuse or Assault during adulthood |
Yes
No
|
| If you would like to explain the nature of the abuse, you may do so below. |
| |
| 65) Choose the number that best describes your abortion experience |
1-Low Stress
2
3
4-Moderate Stress
5
6
7-High Stress
8
9
10-Overwhelming
|
| PLEASE FEEL FREE TO SHARE ANY OTHER COMMENTS OR THOUGHTS ABOUT YOUR PERSONAL ABORTION EXPERIENCE. |
|
| THANK YOU FOR COMPLETING THIS SURVEY AND FOR PARTICIPATING IN OUR RESEARCH. IF YOU BELIEVE YOU MAY NEED OR BENEFIT FROM COUNSELING, CLICK "LINKS" ON SIDEBAR FOR REFERRAL INFORMATION. |
| |
